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。     

Intraoperative endoscopic retrograde cholangio-pancreatography: A useful tool in the hands of the hepatobiliary surgeon

AIM: To evaluate the efficacy of intraoperative endoscopic retrograde cholangio-pancreatography(ERCP) combined with laparoscopic cholecystectomy(LC) forpatients with gall bladder stones(GS) and common bile duct stones(CBDS).METHODS: Patients treated for GS with CBDS were included. LC and intraoperative transcystic cholangiogram(TCC) were performed in most of the cases. Intraoperative ERCP was done for cases with proven CBDS.RESULTS: Eighty patients who had GS with CBDS were included. LC was successful in all cases. Intraoperative TCC revealed passed CBD stones in 4 cases so intraoperative ERCP was performed only in 76 patients. Intraoperative ERCP showed dilated CBD with stones in 64 cases(84.2%) where removal of stones were successful; passed stones in 6 cases(7.9%); short lower end stricture with small stones present in two cases(2.6%) which were treated by removal of stones with stent insertion; long stricture lower 1/3 CBD in one case(1.3%) which was treated by open hepaticojejunostomy; and one case(1.3%) was proved to be ampullary carcinoma and whipple’s operation was scheduled. CONCLUSION: The hepatobiliary surgeon should be trained on ERCP as the third hand to expand his field of therapeutic options.     

Treatment of choledocholithiasis: therapeutic ERCP versus peroperative extraction during laparoscopic cholecystectomy

Limitation for preoperative ERCP/ES before laparoscopic cholecystectomy in patients scheduled for laparoscopic cholecystectomy are (1) Additional invasiveness of endoscopic procedures in patients supposed to be fitted for surgery, (2) A high rate of useless procedures due to the low predictive value of suspicion criteria for common bile duct stones (CBDS), (3) an inability to detect and treat all patients with CBDS, and (4) so far, an absence of demonstration of the superiority of this split therapeutic approach versus a one stage surgical treatment. Published series of CBDS extraction during laparoscopic cholecystectomy have included more than 2000 patients. Results and complications of this one stage laparoscopic approach compares favourably to the conventional open surgical treatment. In one randomized trial endoscopy plus laparoscopy was not demonstrated superior to laparoscopy alone. Intraoperative diagnosis and treatment of CBDS during laparoscopic cholecystectomy is the most cost efficient approach for patients with or without preoperative suspicion of CBDS, provide they are fitted for surgery.     

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.     

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.     

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.     

Advances of recurrent risk factors and management of choledocholithiasis

Gallstone disease is a common and frequently occurring disease in human, and it is the main disease among the digestive system diseases. The incidence of gallstone disease in western countries is about 5%–22%, and common bile duct stones (CBDS) accounts for 8%–20%. CBDS easily lead to biliary obstruction, secondary cholangitis, pancreatitis, and obstructive jaundice, even endanger life. Therefore, it needs timely treatment once diagnosed. The recurrence of choledocholithiasis after bile duct stones clearance involves complicated factors and cannot be completely elaborated by a single factor. The risk factors for recurrence of choledocholithiasis include bacteria, biliary structure, endoscopic and surgical treatment, and inflammation. The modalities for management of choledocholithiasis are endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic or open common bile duct exploration, dissolving solutions, extracorporeal shockwave lithotripsy (ESWL), percutaneous radiological interventions, electrohydraulic lithotripsy (EHL) and laser lithotripsy. We compare the different benefits between surgery and ERCP. And finally, we make a summary of the current strategy for reducing the recurrence of CBDS and future perspectives for CBDS management.     

Diagnosis and management of choledocholithiasis in the golden age of imaging,endoscopy and laparoscopy

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones(CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound(EUS) and magnetic resonance cholangiography(MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and costeffectiveness of imaging techniques used to identifyCBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

Choledocholithiasis： Evolving standards for diagnosis and management

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecys-tectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraop-eratively or postoperatively Multiple modalities are available for assessing patients for Choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancrea-tography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intra-operative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.     

Where do ERCP, endoscopic ultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography fit in the management of acute biliary pancreatitis? A decision analysis model

OBJECTIVES: The role of ERCP in acute biliary pancreatitis (ABP) is controversial. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasonography (EUS) are modalities for bile duct visualization that could lower costs and prevent ERCP-related complications. We analyzed costs and examined the cost-effectiveness of these modalities to define their role in ABP. METHODS: A decision analysis model of ABP was constructed. The strategies evaluated were 1) ERCP, 2) MRCP followed by ERCP if positive for common bile duct stones (CBDS) or if biliary sepsis ensued, 3) EUS followed by ERCP if positive or if biliary sepsis ensued, and 4) observation with intraoperative cholangiography at the time of cholecystectomy with ERCP only if biliary sepsis ensued. We compared costs and performed cost-effectiveness analysis between strategies at probabilities of CBDS ranging from 0% to 100%. The outcome measures were total costs and costs per ABP death prevented. RESULTS: At probabilities of CBDS < 15%, observation with intraoperative cholangiography is the least expensive strategy, whereas EUS and ERCP are the least expensive strategies at probabilities of 15-58% and >58%, respectively. In terms of cost-effectiveness, at probabilities of CBDS of 7-45%, EUS is the most cost-effective alternative, and at a probability of >45% ERCP is the most cost-effective option. CONCLUSIONS: Total costs and cost-effectiveness ratios of these strategies in patients with ABP are highly dependent on the probability of CBDS.     

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.     

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．     

Imaging tests for accurate diagnosis of acute biliary pancreatitis

Gallstones represent the most frequent aetiology of acute pancreatitis in many statistics all over the world, estimated between 40%-60%. Accurate diagnosis of acute biliary pancreatitis(ABP) is of outmost importance because clearance of lithiasis [gallbladder and common bile duct(CBD)] rules out recurrences. Confirmation of biliary lithiasis is done by imaging. The sensitivity of the ultrasonography(US) in the detection of gallstones is over 95% in uncomplicated cases, but in ABP, sensitivity for gallstone detection is lower, being less than 80% due to the ileus and bowel distension. Sensitivity of transabdominal ultrasonography(TUS) for choledocolithiasis varies between 50%-80%, but the specificity is high, reaching 95%. Diameter of the bile duct may be orientative for diagnosis. Endoscopic ultrasonography(EUS) seems to be a more effectivetool to diagnose ABP rather than endoscopic retrograde cholangiopancreatography(ERCP),which should be performed only for therapeutic purposes.As the sensitivity and specificity of computerized tomography are lower as compared to state-of-the-art magnetic resonance cholangiopancreatography(MRCP)or EUS,especially for small stones and small diameter of CBD,the later techniques are nowadays preferred for the evaluation of ABP patients.ERCP has the highest accuracy for the diagnosis of choledocholithiasis and is used as a reference standard in many studies,especially after sphincterotomy and balloon extraction of CBD stones.Laparoscopic ultrasonography is a useful tool for the intraoperative diagnosis of choledocholithiasis.Routine exploration of the CBD in cases of patients scheduled for cholecystectomy after an attack of ABP was not proven useful.A significant rate of the so-called idiopathic pancreatitis is actually caused by microlithiasis and/or biliary sludge.In conclusion,the general algorithm for CBD stone detection starts with anamnesis,serum biochemistry and then TUS,followed by EUS or MRCP.In the end,bile duct microscopic analysis may be performed by bile harvested during ERCP in case of recurrent attacks of ABP and these should be followed by laparoscopic cholecystectomy.     

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)...     

ERCP and endoscopic sphincterotomy in infants and children with jaundice due to common bile duct stones.

ERCP was performed in two infants (29 and 62 days old) and eight children (5 to 12 years old) with jaundice due to common bile duct stones. Seven patients had hemolytic anemia and three patients had a family history of gallstone disease. Successful cannulation of the common bile duct demonstrating stones was accomplished in all patients. Four patients had coexisting gallstones and were treated surgically. Six children who had previously undergone cholecystectomy were treated by endoscopic sphincterotomy and stone extraction without complication. We believe that ERCP should be utilized by expert endoscopists in children with evidence of extra-hepatic cholestasis, and endoscopic sphincterotomy should be the treatment of choice in children who have previously undergone cholecystectomy, and who are jaundiced secondary to common bile duct stones.     

Management of gallbladder and common bile duct stones: Laparoscopic cholecystectomy combined with preoperative endoscopic sphincterotomy versus open surgery

Laparoscopic cholecystectomy (LC) combined with preoperative endoscopic sphincterotomy (EST) is becoming more widely employed as a therapeutic option for the management of gallbladder stones (GBS) and common bile duct stones (CBDS). To compare the results of LC plus preoperative EST with the results of open surgery, in terms of morbidity, mortality, hospital stay, length of operation, and hospital cost, we reviewed the charts of 105 patients who had concomitant GBS and CBDS: in 34, preoperative EST had been attempted, and 71 had undergone open surgery. Twenty-six of the 71 patients who had undergone open cholecystectomy, common bile duct exploration, and T-tube placement were selected for comparison as a T-tube group, since they had exhibited no condition that contraindicated LC. EST was unsuccessful in 6 of the 34 patients in whom it was attempted, and all 6 underwent open surgery. Successful EST and duct clearance were achieved in 28 patients (82.4%); 4 of them had serious medical problems and were followed without operation, 7 underwent open cholecystectomy, and the remaining 17 underwent LC (LC-after-EST group). Total hospital stay was longest in the 6 patients who underwent open surgery because of unsuccessful EST, and their total hospital cost was significantly higher than that of the patients in the LC-after-EST group. Operation time, rate of early postoperative complications, and hospital stay were significantly lower in the LC-after-EST group than in the T-tube groups, although total hospital cost was not different. The combination of preoperative EST and LC is a safe and effective option for the management of GBS and CBDS. However, when EST is unsuccessful and the patient is switched to open surgery, the hospital stay is much longer and more costly than when EST and LC are successful. The patient should be informed of the disadvantages if EST should fail.     

Laparoscopic exploration of the common bile duct through a choledochotomy: Report of three cases

This article reports three cases of totally intraabdominal laparoscopic exploration of the common bile duct via a choledochotomy with extraction of stones. The patients had failed endoscopic retrograde cholangiopancreatography (ERCP) stone extraction because of the size of the stones in two instances, and in the third, because of the presence of a duodenal diverticulum. This procedure is a promising solution to the problem of large common bile duct (CBD) stones in centers which have established laparoscopic cholecystectomy expertise.     

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.     

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.