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World J Gastrointest Surg. Feb 27, 2023; 15(2): 169-176
Published online Feb 27, 2023. doi: 10.4240/wjgs.v15.i2.169
Current management of concomitant cholelithiasis and common bile duct stones
Efstathios T Pavlidis, Theodoros E Pavlidis
Efstathios T Pavlidis, Theodoros E Pavlidis, 2nd Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
Author contributions: Pavlidis TE designed the research, contributed new analytic tools, analyzed data and reviewed; Pavlidis ET performed the research, analyzed the data review and wrote the paper.
Conflict-of-interest statement: All authors report having no relevant conflicts of interest related to this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Theodoros E Pavlidis, Doctor, PhD, Full Professor, Surgeon, 2nd Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece. pavlidth@auth.gr
Received: November 4, 2022
Peer-review started: November 4, 2022
First decision: November 27, 2022
Revised: November 27, 2022
Accepted: January 16, 2023
Article in press: January 16, 2023
Published online: February 27, 2023
Processing time: 115 Days and 6.8 Hours
Abstract

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

Keywords: Biliary diseases; Cholelithiasis; Choledocholithiasis; Gallstones; Endoscopic management; Laparoscopic management

Core Tip: One- or two-stage management of concurrent cholelithiasis and choledocholithiasis is safe and acceptable and does not show significant differences. Current diagnostic tools and interventional techniques can offer the optimal outcome, especially in difficult cases or recurrent stones. The relevant training and gained expertise play an essential role in performing the kind of available and acceptable method of minimally invasive treatment.