Management of common bile duct stones: controversies and future perspectives

BACKGROUND: The advent of endoscopic and minimally invasive techniques for diagnosis and treatment has revolutionised the management of bile duct stones. Yet several controversies still surround the optimal means of investigation and treatment. DISCUSSION: Scoring systems that classify patients according to their risk of harbouring bile duct stones are likely to decrease the number of unnecessary preoperative endoscopic cholangiopancreatograms (ERCPs) at the expense of a higher rate of positive intra-operative diagnosis, unless magnetic resonance cholangiopancreatography (MRCP) is used to supplement the clinical information. The current treatment that is generally preferred for patients with a high probability of bile duct stones is ERCP followed by laparoscopic cholecystectomy (LC), but the routine use of ERCP in this context has certain limitations. An alternative approach is offered by carrying out the necessary cholangiogram during LC. Laparoscopic choledochotomy requires technical skill and costly equipment and should usually be followed by T-tube drainage of the duct. A recent survey in Spain has shown that most surgeons prefer ERCP plus LC, but one recent randomised controlled trial showed advantages for the single-stage laparoscopic treatment of bile duct stones in terms of a shorter hospital stay; success rates and complication rates were similar for the two procedures. The authors support the consensus statement that the choice of diagnostic and therapeutic strategy should depend on local circumstances and available expertise.     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．     

Endoscopic Retrograde Cholangiopancreatography in Laparoscopic Cholecystectomy

Abstract: With the widespread use of laparoscopic cholecystectomy (LC), the role of pre- and postoperative endoscopic retrograde cholangiopancreatography (ERCP) and / or endoscopic sphincterotomy (ES) has become very important. Indications for ERCP with possible ES before LC include clinical suspicion of a common bile duct (CBD) stone alone, evidence of jaundice, recent cholangitis or pancreatitis that is probably due to a duct stone or dilated CBD. Local endoscopic and surgical expertise are important factors in deciding the approach to the pre-LC patients. The success rate of ductal clearance of stones by ES approaches 90 to 95% in expert hands. ERCP is very effective in the management of post-LC patients with symptoms, as well as in diagnosing and treating complications such as retained stones, ductal leaks and strictures.     

逆行胰胆管造影、乳头括约肌切开配合腹腔镜胆囊切除术治疗胆石症

为治疗伴有或可疑伴有胆总管结石的胆囊结石病人，在对胆囊结石病人行腹腔镜胆囊切除术（ＬＣ）时，对ＬＣ术前可疑伴有胆总管继发性结石的１４２例病人（术前组）和ＬＣ术后可疑胆总管残留结石的３９例病人（术后组）选择性地行逆行性胰胆管造影（ＥＲＣＰ）检查和乳头括约肌切开术（ＥＳＴ）治疗。结果：术前组ＥＲＣＰ发现胆总管继发结石６５例，ＥＳＴ清除结石６０例，清除率９１．５％；术后组ＥＲＣＰ发现胆总管残留结石６例，ＥＳＴ清除结石５例。结果提示ＥＲＣＰ、ＥＳＴ配合ＬＣ治疗伴有胆总管结石的胆囊结石病人是一种安全有效的好方法，明显减少了ＬＣ的并发症和胆总管结石开腹手术的比例。     

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.     

Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones,stents and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy.In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.     

Handling of biliary complications following laparoscopic cholecystectomy in the setting of Tripoli Central Hospital

BackgroundLaparoscopic cholecystectomy (LC) has an increased incidence of bile duct injury and bile leak when compared with open cholecystectomy. This study reviews management of these complications in a general hospital setting. Data collected from patients diagnosed and treated in one surgical unit for biliary complications after LC between 1992 and 1996 were analysed.MethodA total of 14 patients were examined. Diagnosis was defined mainly by Endoscopic retrograde cholangiopancreatography (ERCP) and undetected choledocholitiasis was discovered in association with two of these complications. 43% of patients presented after LC with early postoperative bile leak or jaundice due to partial or complete bile duct excision or slippage of clips from the cystic duct. 57% presented with late biliary strictures. Thirteen patients were treated surgically, with biliary reconstruction (11 patients), direct repair (one) and cystic duct ligation in combination with clearance of bile duct from large multiple stones (one). One patient,who had clip displacement from cystic duct in combination with misplaced clip on right hepatic duct, was treated elsewhere. Postoperatively, one patient developed anastomotic leak and another died from sequellaie of bile duct transection requiring staged operations.ConclusionsIt is concluded that, in an environment similar to that where the authors had to work, LC should be performed in hospitals with facility to perform ERCP or when access for this technique is available in a nearby institution. Early recognition and immediate management of biliary injuries is dependent on individual resources and circumstances but, if required, consultation with colleagues or referral of patients with suspected or established biliary complications should not be delayed.     

三种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效比较

目的 探讨3种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效与并发症.方法 选取我院2016年7月至2019年6月收治的178例胆囊结石并发肝外胆管结石的老年病人作为研究对象,其中63例采用腹腔镜胆囊切除术联合腹腔镜胆总管探查术(LC+LCBDE),61例采用内镜逆行胰胆管造影联合腹腔镜胆囊切除术(ERCP+LC)...     

Surgery in biliary lithiasis: from the traditional"open" approach to laparoscopy and the"rendezvous" technique

BACKGROUND:According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influ-enced new approaches to the management of CBDS in associ-ation with gallstones. DATA SOURCES: We decided to systematically review the lit-erature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed in-dependently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central.RESULTS: The therapeutic approach nowadays varies great-ly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS: Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.     

Endoscopy for bile duct stones

In the era of laparoscopic cholecystectomy and advanced non-invasive imaging studies, pre-operative endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones should be reserved for selected patients. ERCP remains the therapy of choice for removal of bile duct stones in the post-cholecystectomy patient and in patients with intact gallbladders. Bile duct stones can be cleared in nearly all patients using endoscopic techniques of sphincterotomy and mechanical lithotripsy. Difficult or complex bile duct stones can be endoscopically removed in the majority of patients with additional techniques such as extracorporeal shock wave lithotripsy, intraductal lithotripsy and/or stent placement. In non-operative patients in whom stone clearance cannot be achieved, long-term stent placement is a potential option in patients who are not candidates for further therapy. Endoscopic therapy may be effective in selected patients with intrahepatic biliary stones.     

Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy.

Options for managing the common bile duct during laparoscopic cholecystectomy include routine peroperative cholangiography and selected preoperative endoscopic retrograde cholangiopancreatography (ERCP). The use of these methods was reviewed in 350 patients with symptomatic gall stones referred for laparoscopic cholecystectomy. Unit A (n = 114) performed routine cystic duct cholangiography but undertook preoperative ERCP in patients at very high risk of duct stones only; unit B (n = 236) performed selected preoperative ERCP on the basis of known risk factors for duct stones. The detection rate for common bile duct stones was similar for units A and B (16% v 20%). In unit A, five of seven patients who had preoperative ERCP had duct stones. Operative cholangiography was technically successful in 90% of patients and duct stones were confidently identified in 13, one of whom went on to immediate open duct exploration. Postoperative ERCP identified duct stones in only four patients, indicating spontaneous passage in eight. In unit B, preoperative ERCP was undertaken in 76 of 236 (32%) patients and duct stones were identified in 47 (20%). Duct clearance was successful in 42 (18%) but failed in five (2%), necessitating elective open duct exploration. Both protocols for imaging the common bile duct worked well and yielded satisfactory short term results.     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

Combination of Preoperative EST,Laparoscopic Cholecystectomy with Choledochotomy,and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32-year-old man was admitted to our hospital because of jaundice and right hypochon-dralgia of several-days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.     

Endoscopic management of bile duct stones

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.     

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM: To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS: Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.RESULTS: Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.CONCLUSION: Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient’s condition, operator’s expertise and local resources should be taken into account in making treatment decisions.     

Diagnostic value of magnetic resonance cholangiopancreatography for clinically suspicious spontaneous passage of bile duct stones

Background and Aim: We investigated the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in patients with clinically suspicious spontaneous passage of bile duct stones. Methods: The study population consisted of 113 patients suspected of having common duct bile stones. Of them, 50 patients were clinically suspected of spontaneous passage of bile duct stones based on the presence of gallbladder stones on ultrasound examination or a history of common bile duct stones after cholecystectomy, clinical symptoms including abdominal pain and fever associated with inflammatory reaction and marked rise of hepatobiliary enzymes which resolved or normalized after conservative treatment without evidence of stones in the common bile duct on MRCP. These 50 patients were prospectively followed up for a median of 10.2 months. Results: All patients except for one had had no symptoms related to cholangitis. Only one patient received ERCP due to recurrence of symptoms after 6 months. Conclusion: When clinical symptoms improve, hematological parameters normalize, and MRCP indicates that there are no stones in the common bile duct, it can be considered that the stones have passed naturally.     

Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique

BACKGROUND: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.     

Selection criteria for pre-operative endoscopic retrograde cholangiography and endoscopic-laparoscopic treatment of biliary stones.

OBJECTIVE: Pre-operative endoscopic retrograde cholangiography (ERCP) prior to laparoscopic cholecystectomy (LC) is the most common treatment of gallbladder and common bile duct (CBD) stones. In this study we evaluate our selection criteria for pre-operative ERCP and the results of endoscopic-laparoscopic treatment in patients with CBD stones. DESIGN: Consecutive adult patients admitted to the department of surgery because of symptomatic cholelithiasis were included in a prospective open trial. PARTICIPANTS: Between January 1996 and December 1996, 841 patients underwent LC at our hospital. ERCP pre-LC was performed in 95 of the 841 patients, on the basis of our selection criteria. INTERVENTIONS: The indication to perform ERCP was suggested by a dilatated CBD (> 10 mm) or ductal stones, abnormal serum liver tests, persisting for more than 3 days, jaundice, cholangitis or pancreatitis. Twelve months after surgery, all patients were contacted by telephone to exclude symptoms related to residual stones. RESULTS: Cannulation of the CBD was successful in 94 of 95 patients submitted to pre-LC ERCP. CBD stones were found in 87 patients (95.6%) in 22 of whom (25.2%) they were in the form of small stones or sludge. In only three of 94 patients (3.2%) no alterations of the CBD or papilla were found. Complications occurred in eight of 98 patients (in five after endoscopic sphincterotomy (ES), and in three after LC). CONCLUSIONS: Pre-operative ES in selected patients with coexisting gallbladder and CBD stones has been a good approach and the criteria that we used for selection of patients to be submitted to pre-operative ERCP/ES seem to be effective.     

Current status of laparoscopic therapy of cholecystolithiasis and common bile duct stones

BACKGROUND: Laparoscopic cholecystectomy (LC) is the standard operation for gallstone disease. The aim of this review was to scrutinize the advantages and benefits of this minimal invasive technique compared to the conventional operation according to the available literature. Regarding the evidence-based medicine criteria, the current status of laparoscopy in the treatment of cholecystolithiasis, cholecystitis and common bile duct stones has been worked out. METHODS: A Medline, PubMed, Cochrane search. RESULTS: Ten randomized controlled trials (RCTs) are available comparing laparoscopic versus open cholecystectomy. The superiority of LC in less postoperative pain, shorter recovery and hospital stay is stated. Operation time was longer in the first years of LC. 3 RCTs deal with acute cholecystitis: one paper could not find any significant advantage of LC over conventional cholecystectomy, the other two found benefits in recovery, hospital stay and postoperative pain. The range of conversion is between 5 and 7% in elective cases and increases up to 27% for acute cholecystitis. With a rate of more than 90% in Europe, the standard procedure for common bile duct stones is 'therapeutic splitting' with endoscopy and retrograde cholangiopancreatography preoperatively followed by LC. Laparoscopic bile duct clearance is effective and safe in experienced hands, however, the only proven benefit is a slightly shorter hospital stay. CONCLUSION: The laparoscopic approach is preferred in elective cholecystectomy and acute cholecystitis. The minimal invasive technique has proven to be effective, gentle and safe. The main benefits are evident within the first postoperative days.