Minimally invasive treatment of cholecysto-choledocal lithiasis: The point of view of the surgical endoscopist

Abstract

The rate of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be approximately 10%-33%, depending on the patient’s age. Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery and improvement of diagnostic procedures have influenced new approaches to the management of common bile duct stones in association with gallstones. At present available minimally-invasive treatments of cholecysto-choledocal lithiasis include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Published data evidence that, associated endoscopic-laparoscopic approach necessitates increased number of procedures per patient while single-stage laparoscopic treatment is associated with a shorter hospital stay. However, current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. Endoscopic retrograde cholangiopancreatography/EST should be adopted on a selective basis, i.e., in patients with acute obstructive suppurative cholangitis, severe biliary pancreatitis, ampullary stone impaction or severe comorbidity. In a setting where all facilities are available, decision in the selection of the therapeutic option depends on the patients, the number and size of choledocholithiasis stones, the anatomy of the cystic duct and common bile duct, the surgical history of patients and local expertise.

Keywords: Cholecysto-choledocal lithiasis; Laparoscopic treatment; Endoscopic treatment; Minimally invasive therapy; Management strategies

Core tip: Development of Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Surgery have influenced new approaches to the management of cholecysto-choledocal lithiasis. At present available minimally-invasive treatments include: single-stage laparoscopic treatment, perioperative endoscopic treatment and endoscopic treatment alone. Current data does not suggest clear superiority of any one approach with regard to success, mortality, morbidity and cost-effectiveness. Considering the variety of therapeutic options available for management, a critical appraisal and decision-making is required. This should preferably be dictate on the patient, the clinical presentation, the timing of diagnosis (established pre-operative diagnosis or incidental intraoperative diagnosis), the surgical pathology and the local expertise.