Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Abstract

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Keywords: Gallbladder stones, Choledocholithiasis, Laparoscopic cholecystectomy, Rendezvous technique, Management of biliary lithiasis, Endoscopic retrograde cholangio-pancreatography

Core Tip: Gallstone disease associated with common bile duct stones is a common clinical scenario. Laparoscopic cholecystectomy is considered the gold standard for treatment of symptomatic gallbladder stones; conversely, the best treatment option for bile duct stones remains uncertain and controversial. We discuss herein the epidemiology, natural history, clinical presentations, preoperative diagnosis, management, complications, and different methods of treatment.