Choledocholithiasis: evolving intraoperative strategies

In the era of open cholecystectomy, common bile duct stones were approached by traditional choledocholithotomy. Retained or recurrent stones discovered after cholecystectomy were approached by endoscopic extraction techniques or repeat surgery. With the advent of laparoscopic cholecystectomy, the approach to choledocholithiasis became more problematic as techniques for laparoscopic extraction were rudimentary. Preoperative endoscopic retrograde cholangiopancreatography rapidly became an adjunct to laparoscopic cholecystectomy when common duct stones were likely. Experience, however, revealed that many of these procedures were unnecessary. With developing sophistication of laparoscopic techniques, a variety of approaches to common duct stones developed. These included: transcystic extraction, direct laparoscopic choledocholithotomy, intraoperative endoscopic retrograde cholangiopancreatography, antegrade sphincterotomy, and transcystic placement of a common duct stent with subsequent endoscopic sphincterotomy and stone extraction. It is the purpose of this article to define the current role of each of these methods in the laparoscopic approach to choledocholithiasis.     

Laparoscopic cholecystectomy. The new 'gold standard'?

Laparoscopic cholecystectomy has rapidly been adopted by surgeons, but concerns remain about its safety, the management of common bile duct stones, and the means of appropriate training. Of 647 patients referred for cholecystectomy, preoperative endoscopic retrograde cholangiography was performed in 49 (7.6%), with 27 patients (4%) undergoing sphincterotomy and stone extraction. Traditional cholecystectomy was performed in 29 patients (4.5%). Laparoscopic cholecystectomy was attempted in 618 patients and completed successfully in 600 (97.1%). Surgical trainees functioned as the primary surgeon in 70% of cases. Technical complications occurred in three patients (0.5%), including one patient with a common bile duct laceration (0.2%). Major complications occurred in 10 patients (1.6%), with no perioperative mortality. Mean postoperative hospital stay was 1 day, with return to work or full activity a mean of 8 days after surgery. Two cases of retained common bile duct stones (0.3%) were identified. We now regard laparoscopic cholecystectomy as the "gold standard" therapy for management of symptomatic cholelithiasis.     

十二指肠镜、腹腔镜序贯治疗胆石症2 248例分析

目的探讨十二指肠镜、腹腔镜序贯性诊治胆石症的价值. 方法回顾性分析2000年1月～2004年12月采用十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症2 248例的临床资料. 结果确诊胆囊结石1 817例,胆囊结石合并胆总管结石431例.B超诊断为胆囊结石2 021例中,行术前ERCP 690例,发现胆总管结石213例;术中胆道造影(IOC)85例,发现胆总管结石10例;腹腔镜胆囊切除(LC)术后胆总管残余结石6例,并经EST治愈.B超诊断胆囊结石合并胆总管结石227例中,ERCP证实胆总管结石202例.行LC 1 817例,EST LC 395例,LBDE 36例(其中胆管一期缝合26例,T管引流10例).全组中转开腹28例(1.2%),并发症52例(2.3%). 结论十二指肠镜、腹腔镜序贯性诊治方案治疗胆石症,体现了内镜、腔镜联合应用的优势,术后残余结石率低,微创治疗成功率高.     

Laparoscopic Management of Gallbladder Disease in Children and Adolescents

Background:

Between July 1991 and April 1996, 40 children and adolescents age 17 or less underwent laparoscopic management of their gallbladder disease. Twenty-eight patients were females and 12 were males. Their average age was 12.7 years (range 2-17 years), and average weight was 50 kilograms, range 12.2-95.9 kilograms. Nine patients had gallstone pancreatitis and seven patients had sickle cell disease. Laparoscopic cholecystectomy was attempted in all patients with or without modifications of the standard technique dictated by the size of the patient.

Methods:

The practice of intraoperative cholangiogram varied with the practicing surgeon. Those with clinical or biochemical evidence of common bile duct obstruction underwent preoperative endoscopic retrograde cholangiopancreatography to rule out other causes of hyperbilirubinemia and/or therapy for choledocholithiasis if present. Patients with unsuccessful intraoperative cholangiogram were followed clinically and were subjected to postoperative endoscopic retrograde cholangiopancreatography should they develop clinical or biochemical evidence of common bile duct obstruction. Thirty-six patients were completed laparoscopically (90%). Four patients were converted to open cholecystectomy (10%). Four patients required preoperative endoscopic retrograde cholangiopancreatography and were successfully treated. Postoperative endoscopic retrograde cholangiopancreatography was unsuccessful in one patient who required the procedure because of retained common bile duct stone. Four patients suffered complications (10%). Three patients continued to have abdominal pain that was not helped with surgery.

Conclusions:

Based on our experience, laparoscopic cholecystectomy with preoperative endoscopic retrograde cholangiopancreatography if required, is safe and effective in management of gallbladder disease in children and adolescents. However, careful preoperative evaluation is required to avoid persistent postoperative abdominal pain.     

Bile leak from the accessory biliary duct following laparascopic cholecystectomy

Anatomists and surgeons have described the presence of accessory biliary ducts between the liver and gallbladder. Bile leakage from accessory duct following laparoscopic cholecystectomy (LC) is an unusual post-operative complication. Aim of the study was to assess its incidence, the intraoperative methods helpful for notice the anatomical anomaly and the impact of endoscopic procedure as a suitable treatment. From January 1997 to September 2002, 185 patients underwent LC for symptomatic cholelithiasis in our surgical department. Post-operative bile leakage from accessory biliary duct occurred in two patients (1%): one case from the liver bed of gallbladder (duct of Luschka) and one case from an aberrant cholecystohepatic duct entering Hartmann's pouch. One patient underwent open celiotomy because of unavailability of endoscopic retrograde cholangiopancreatography. The other patient was successfully treated by endoscopic sphincterotomy and nasobiliary tube placement. By careful dissection, accessory ducts were noticed and clipped in three other patients with overall incidence of 2.7%. Meticulous laparoscopic technique aimed to careful recognize all structures during LC is the main policy to contain biliary injury within its nadir incidence. Depending of availability, endoscopic sphincterotomy and nasobiliary drainage allow diagnosis and treatment of bile leakage, preserving the effectiveness of laparoscopic procedure.     

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY

Laparoscopic cholecystectomy is the preferred method of treatment for symptomatic choledocholithiasis. Since its introduction there has been an increase in postoperative diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study was to assess the indications and results of ERCP following laparoscopic cholecystectomy. Sixty-one patients had an ERCP following laparoscopic cholecystectomy. Two broad groups were identified: Group 1 (35 patients) had filling defects (consistent with stones) noted on operative cholangiography, which were not successfully flushed or extracted at the time of laparoscopic cholecystectomy; Group 2 consisted of patients who developed problems following laparoscopic cholecystectomy. Nine patients had post-laparoscopic cholecystectomy pain with abnormal liver function tests (LFT), four of whom had common bile duct (CBD) injuries and three had CBD stones. Eleven patients had post-laparoscopic cholecystectomy pain with a normal diameter common bile duct on ultrasound and normal LFT; only one had a CBD stone. Five patients with a persisting bile leak following laparoscopic cholecystectomy had an ERCP and endoscopic sphincterotomy. In three the leak ceased, while two required subsequent open surgery to drain bile collections and ligate the cystic duct. One patient presented with an episode of transient jaundice but had a normal ERCP. There were six post-ERCP complications; three patients had mild pancreatitis, two had a minor haemorrhage and one an asymptomatic duodenal perforation. Endoscopic retrograde cholangiopancreatography post-laparoscopic cholecystectomy was most valuable for the management of retained stones and the diagnosis and management of post-laparoscopic cholecystectomy pain in association with abnormal LFT. The diagnostic yield was low (9%) when the LFT were normal.     

Endolaparoscopic rendezvous treatment: a satisfying therapeutic choice for cholecystocholedocolithiasis

BACKGROUND: There are many different strategies for the treatment of the main bile duct lithiasis. When lithiasis of the biliary tract is suspected at a preoperative stage, we can treat patients with sequential treatment: endoscopic netrograde cholangiopancreatography followed by laparoscopic cholecystectomy. If common bile duct-lithiasis is recognized at an intraoperative stage, many options for treatment exist, one of which is intraoperative retrograde endoscopic sphincterotomy (ES) (laparoendorendezvous). METHODS: We report our experience using the aforementioned technique with 58 patients affected by cholelithiasis and complex Common bile duct disease who underwent laparoscopic cholecystectomy and intraoperative ES consecutively from March 1996 to May 2000. Of the 58 patients, 43 were affected by cholecystocholedocolithiasis: 12 by previously described lithiasis plus stenosant papillitis, 2 also by a pancreas head cancer, and 1 by cancer of the papilla. RESULTS: The combined technique was performed in 86% of the cases. Six patients required conversion to open surgery. In two other patients, laparoscopic choledocotomy was performed with positioning of a Kehr-tube for an ampulla-impacted lithiasis. CONCLUSIONS: Intraoperative ES offers a valid approach to the treatment of cholecystocholedocolithiasis in one session. Furthermore, it represents a valid alternative to transcholedocical laparoscopic treatment of cholelithiasis and complex common bite duct pathology.     

Selective operative cholangiography and Perioperative endoscopic retrograde cholangiopancreatography (ERCP) during laparoscopic cholecystectomy

BACKGROUND: Most common bile duct (CBD) stones can now be removed by minimally invasive methods using pre- or postoperative endoscopic sphincterotomy. A few centers explore the bile duct laparoscopically, but not every hospital has access to the equipment for magnetic resonance (MR) cholangiopancreatography to diagnose ductal stones. This study shows the results of an alternative management option. METHODS: We did a retrospective review of perioperative endoscopic retrograde cholangiopancreatographies (ERCPs) and sphincterotomies that were performed on patients in whom choledocholithiasis had been revealed on operative cholangiogram. RESULTS: Thirteen patients underwent perioperative ERCP. Nine had successful duct clearance, three had failure to cannulate, and one was converted to an open procedure due to an anatomical problem. The combined median operating time for both procedures was 75 min and hospital stay was 2.5 days. No pancreatitis was reported. CONCLUSION: Selective operative cholangiography and perioperative ERCP during laparoscopic cholecystectomy is a viable option for the simultaneous management of CBD and gallbladder stones. Moreover, it helps to avoid unnecessary normal ERCP.     

Bile leak after laparoscopic cholecystectomy

Summary Laparoscopic cholecystectomy has now become the preferred surgical approach to symptomatic cholelithiasis. With the widespread use of this technique there have appeared reports of complications. We report the case of a patient who developed a cystic duct stump bile leak after laparoscopic cholecystectomy. Percutaneous drainage of the biloma, endoscopic retrograde cholangiopancreatography and papillotomy led to resolution of the problem. The literature on cystic duct stump leaks after laparoscopic cholecystectomy is reviewed and the various therapeutic modalities are outlined.     

胆囊结石合并胆总管结石的微创治疗体会

目的:比较腹腔镜胆囊切除术(laparoscopic cholecystectomy,LC)联合腹腔镜胆总管探查术(laparoscopic common bile duct exploration,LCBDE)与内镜逆行胰胆管造影(endoscopic retrograde cholangiopancreatography,ERCP)、内镜十二指肠乳头括约肌切开术(endoscopic sphincterotomy,EST)+LC治疗胆囊结石合并胆总管结石的临床疗效。方法:在2010年1月至2015年11月收治的胆囊结石合并胆总管结石患者中选取可耐受腹腔镜手术、ERCP且ASA分级为Ⅰ~Ⅱ级的成年患者作为研究对象,危急重症胆囊炎、急性胆管炎及要求保守治疗的患者未纳入研究。分为两组:LC+LCBDE组与ERCP/EST+LC组,比较分析两组患者术中出血量、手术时间、住院时间、住院费用及术后并发症等指标。结果:共纳入76例患者,30例行LC+LCBDE,其中2例中转开腹;46例行ERCP/EST+LC,其中2例因ERCP取石失败,不予统计。两组患者术中出血量、术后并发症差异无统计学意义,LC+LCBDE组手术时间、住院时间、住院费用优于ERCP/EST+LC组,差异有统计学意义。结论:两种术式治疗胆囊结石合并胆总管结石的疗效相当,但LC+LCBDE可能更加经济实惠。     

The role of laparoscopy in the management of common bile duct obstruction in children

BACKGROUND: Laparoscopic common bile duct exploration is commonplace in adults; however, this procedure is not often performed in children. The goal of this study was to evaluate the results of laparoscopic common bile duct exploration in children. METHODS: Of 50 patients undergoing laparoscopic cholecystectomy, six patients (12%) had obstructing lesions of the common bile duct (CBD). Five children underwent laparoscopic common bile duct exploration, and one child had a preoperative endoscopic sphincterotomy and stone removal. RESULTS: The mean age at laparoscopic CBD exploration was 11.6 years (range, 5-16). The obstructing lesion was visualized by intraoperative cholangiography in all five patients. The mean operative time for laparoscopic cholecystectomy along with CBD exploration was 215 min (range, 160-282). The transcystic laparoscopic CBD exploration was performed using a 7-Fr, multichannel rigid, or 10-Fr flexible fiberoptic cystoscope. The stones were either pushed into the duodenum with the scope or extracted through the cystic duct using a 3-Fr Segura basket. In one patient, a candidial ball disintegrated during an attempt to remove it with the basket. A repeat cholangiogram at the end of each procedure showed an anatomically normal CBD with free flow of contrast into the duodenum. All patients enjoyed a quick recovery. They were started on a regular diet on the same day of surgery and discharged on the 1st or 2nd postoperative day. One patient with sickle cell disease developed a pulmonary infarction and required 5 additional days of hospitalization. One patient developed recurrent choledocholithiasis 6 months after laparoscopic exploration and was treated successfully with endoscopic sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic CBD exploration can be performed safely at the time of the cholecystectomy in children. Endoscopic sphincterotomy before cholecystectomy is not necessary. We recommend laparoscopic CBD exploration for obstructing lesions of the CBD. Endoscopic sphincterotomy should be reserved for recurrent lesions of the CBD after laparoscopic cholecystectomy.     

"Sequential" treatment: is it the best alternative in cholecysto-choledochal lithiasis?

Laparoscopic cholecystectomy has become the treatment of choice for patients with symptomatic cholelithiasis. About 10-20% of patients with gallbladder stones may also present associated common bile duct stones. The management of the latter remains controversial because many different surgical strategies are available: laparoscopic treatment (laparoscopic common bile duct exploration), sequential endoscopic and laparoscopic treatment (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy [ERCP/ES] prior to laparoscopic cholecystectomy), inverted sequential endoscopic-laparoscopic treatment (laparoscopic cholecystectomy followed by ERCP/ES), and combined endoscopic-laparoscopic treatment (laparoscopic cholecystectomy with intraoperative ERCP/ES). The aim of this study was to evaluate the efficacy and safety of sequential endoscopic-laparoscopic treatment in patients with cholecystocholedocholithiasis. We retrospectively analyzed the clinical, biochemical and radiological features of 552 patients operated on for cholelithiasis from 1991 to 2001. Common bile duct stones were suspected on the basis of increased serum levels of bilirubin, GOT, GPT, GGT, alkaline phosphatase; presence of jaundice; history of pancreatitis or cholangitis; dilated common bile duct (diameter > 8 mm) or common bile duct stones at hepatobiliary ultrasonography; presence of common bile duct stones at MR-cholangiography or at i.v. cholangiography. In patients with suspected common bile duct stones, preoperative ERCP was performed; if common bile duct stones were confirmed, ES was performed. When common bile duct stones were not suspected preoperatively, laparoscopic cholecystectomy was performed directly. Overall morbidity, mortality and conversion rates in the two groups were evaluated. Of 552 patients admitted for cholelithiasis, 62 (11.3%) underwent preoperative ERCP for suspected common bile duct stones. In 41 patients (66.1%) common bile duct stones were identified and ES with common bile duct stone extraction was performed in 40 patients (clearance: 97.5%). The overall morbidity was 16% (10 cases of post-ERCP acute pancreatitis); no mortality occurred. The conversion rate during subsequent laparoscopic cholecystectomy was 4.8%. In the group of patients with no suspicion of common bile duct stones, the conversion rate was 4.9%. Sequential treatment cannot be considered the best approach for patients with cholecystocholedocholithiasis because of its morbidity rate and the high rate of negative preoperative ERCP findings. Combined endoscopic-laparoscopic treatment seems to present more advantages, especially in term of morbidity, hospital stay and patient compliance and may, in future, be considered the treatment of choice for patients with cholecystocholedocholithiasis.     

Laparoscopic transduodenal sphincteroplasty

BACKGROUND: Common bile duct stones are a difficult problem, often leading to conversion to an open operation or repeated endoscopic procedures. Both strategies are associated with added morbidity. MATERIALS AND METHODS: A new technique was developed to perform a traditional sphincteroplasty using minimally invasive methods. The procedure was performed on two patients with distal common bile duct stones; each patient had previously undergone at least two unsuccessful preoperative endoscopic retrograde cholangiopancreatography procedures by at least two different experienced endoscopists. Results: In both patients, a laparoscopic transduodenal sphincteroplasty was successfully completed. A transduodenal common bile duct exploration was performed at the time of sphincterotomy, successfully clearing the common bile duct in both cases. There were no untoward postoperative sequelae. Follow-up at one year was satisfactory in both patients. CONCLUSION: Laparoscopic transduodenal sphincteroplasty can be safely performed in patients with common bile duct stones refractory to endoscopic retrograde cholangiopancreatography. This technique offers a new approach to the management of common bile duct stones, and can spare patients the need for an open operation or subsequent endoscopic procedures.     

The benefit of emergency nasobiliary drain in cholelithiasis with ascending cholangitis, coagulopathy, and thrombocytopenia

Severe coagulopathy in a male patient with septicemia, renal failure, and obstructive jaundice secondary to cholelithiasis precluded safe endoscopic sphincterotomy. A temporary nasobiliary drain, inserted at endoscopic retrograde cholangiopancreatography, decompressed the biliary tree, allowing eventual safe sphincterotomy and bile duct clearance after correction of coagulopathy and improvement in his clinical condition.     

Laparoscopic transcystic bile duct stenting in the management of common bile duct stones

Background : The management of patients with common bile duct stones associated with stones in the gall bladder remains controversial. Methods : Over the three‐year period from 1996 to 1999, patients with cholelithiasis and known choledocholithiasis, or choledocholithiasis found at laparoscopic cholecystectomy, were initially treated by placing a stent across the sphincter of Oddi. The stent was pushed along a guide wire through the cystic duct and then down the common bile duct, before the cystic duct was closed. Subsequently, the stent was used to facilitate performance of a needle knife endoscopic sphincterotomy. The stent was then removed, a cholangiography was performed and the common bile duct was cleared. Patients with persistent jaundice usually had a preoperative endoscopic retrograde cholangio‐pancreatography. Results : Transcystic stenting was the ‘intention‐to‐treat’ basis of therapy for 56 of the patients. The placement of the stent only failed once when the stent became trapped in the cystic duct. Complications of the operation included: pain and jaundice (n = 2), cholangitis (n = 1), and pulmonary embolus (n = 1). The median postoperative hospitalization was 2 days (range: 1–15). Five further patients had common bile duct stones removed via a choledochotomy; a stent was placed through the choledochotomy before its closure. The selective common bile duct cannulation rate at the first endoscopic retrograde cholangio‐pancreatography, was 98%. A second endoscopic retrograde cholangio‐pancreatography was required in 15% of patients. The only complication of all the endoscopic procedures was a single case of mild cholangitis; there were no cases of pancreatitis. Conclusion : A treatment option open to all surgeons for non‐jaundiced patients with known choledocholithiasis or choledocholithiasis found at operative cholangiogram, is the transcystic stenting of the sphincter of Oddi at the time of laparoscopic cholecystectomy. At a subsequent sitting, the common bile duct can be safely cleared endoscopically using a sphincterotomy facilitated by the stent.     

Laparoscopic management of difficult recurrent choledocholithiasis.

The management of common bile duct stones has traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of the last century, endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration has become the mainstream treatment for common bile duct stones in most medical centers around the world. However, in some patients, endoscopic retrograde cholangiopancreatography is difficult and laparoscopy is challenging because of previous surgery. These facts are highlighted in this report.     

Sphincter of Oddi-preserving and T-Tube-free Laparoscopic Management of Extrahepatic Bile Duct Calculi

Background  

The current management of choledocholithiasis remains a controversial topic. Popular options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) followed by laparoscopic cholecystectomy (LC), or LC and laparoscopic common bile duct exploration (LCBDE) with T-tube decompression. Some concerns suggest that sphincterotomy has significant long-term complications as a result of sphincter of Oddi (SO) dysfunction, and T-tube decompression is historically associated with many complications and discomfort. The purpose of this study was to demonstrate our simple, safe techniques of LCBDE without a T-tube and with an intact SO.     

Laparoscopic cholecystectomy after bariatric surgery

Background: This prospective study determines the value of laparoscopic cholecystectomy (LC) in patients with cholelithiasis after bariatric surgery. Methods: Eighty-four consecutive patients who underwent bariatric surgery without concomitant cholecystectomy were studied. Patients were divided in two groups; group A including 50 patients (59.5%) without gallbladder disease, and group B included 34 patients (40.5%) with symptomatic cholelithiasis within 2 years postoperatively. Characteristics of both groups were compared and analyzed by the use of chi-square tests. Results: In all 34 patients in group B LC was attempted, and the procedure was successful in 28 (82.4%). LC was converted to open procedure in 6 patients (17.6%). Two patients with choledocholithiasic obstructive jaundice underwent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy prior to laparoscopic management. The mean operative time was 75 ± 12 min, and the mean hospitalization was 2.8 ± 1.1 days. Conclusion: Morbidly obese patients undergoing bariatric surgery are at high risk for developing symptomatic cholelithiasis postoperatively, which usually takes the form of acute cholecystitis. LC is feasible, effective, and seems to be the procedure of choice despite the technical difficulties.     

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.

BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.     

Cholelithiasis in infants, children and adolescents

The prevalence of cholelithiasis is estimated within 0.13% and 2% of children under 19 years of age. Pigment stones are the commonest type of gallstones in children, without recognizable predisposing factors in infants or secondary to a predisposing disease such as chronic hemolysis and ileal disease in children. In adolescents, idiopathic cholesterol gallstones accounts for the majority, such as in adults. Gallbladder stones are found in 80 to 90% of cases and common bile duct stones in 10 to 20% of cases. When common bile duct stones are found, a choledocal cyst with anomalous pancreatobiliary duct junction needs to be excluded. Magnetic resonance cholangiopancreatography should be performed in first line. Cholecystectomy is not indicated for silent gallstones, except in children with a predisposing disease such as chronic hemolysis. Treatment of common bile duct stones includes interventional radiologic, endoscopic or surgical procedures. Stone extraction may be performed at endoscopic retrograde cholangiopancreatography with or without sphincterotomy, combined with laparoscopic cholecystectomy. In children without a predisposing disease or no residual gallstones indicating a cholescystectomy, conservative management (percutaneous cholangiography with biliary drainage) may be proposed in specialised centers, especially for infants. A hepaticojejunostomy is indicated in cases of choledocal cyst with anomalous pancreatobiliary duct junctions.