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.