Laparoscopic common bile duct exploration: long-term outcome

Choledocholithiasis: A Review of Management and Outcomes in a Regional Setting

Background Choledocholithiasis is a common surgical presentation with an incidence of 8% to 16% in symptomatic cholelithiasis. Treatment often requires a multi-stage approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC), which can prolong the length of stay (LoS) and expose patients to unnecessary risks. A single-stage procedure, such as LC with common bile duct exploration (CBDE), is a safe and effective option that may decrease LoS. This study compares patient outcomes and management in a regional center and aims to identify factors that predict the presence of confirmed choledocholithiasis. Methods A retrospective cross-sectional analysis was performed on all patients admitted to Toowoomba Hospital for management of diagnosed or suspected choledocholithiasis from January 2021 to March 2023. Patient demographics, ERCP findings, and operative data were collated. Results A total of 195 patients were identified, including 136 patients undergoing multi-stage management, 34 patients who had an ERCP alone, and 25 patients who underwent single-stage management. Single-stage procedures had an 80% success rate with an average LoS of 3.6 days. Multi-stage procedures had an average LoS of 8.1 days and an ERCP success rate of 93%. Complication rates between ERCP (11.7%) and LC with CBDE (9.7%) were comparable. Time to index ERCP and serum bilirubin level were found to be significantly lower in those with positive index ERCP findings compared to those without. Conclusion Single-stage procedures are a safe way to manage choledocholithiasis and are associated with a reduced LoS when compared to multi-stage management, with comparable efficacy and morbidity rates.

Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) is relatively a new approach for clearing choledocholithiasis. The aim of this study is to assess the safety of this approach to clearing common bile duct (CBD) stones on an index admission including emergency setting.

METHODS

Retrospective data collection and analysis were carried out for 207 consecutive cases of LCBDE performed in Royal Cornwall Hospital over 6 years (2015-2020). Patients were divided into two groups (Index admission vs elective) then both groups compared.

RESULTS

A total of 207 cases of LCBDE were performed in our unit during the time period. One hundred twenty-two operations were performed on the index admission and 85 on a subsequent elective list. Mean operative time was 146 ± 64 min in the index admission group and 145 ± 65 min in the elective group (p = 0.913). Length of stay post-operatively was 3.3 ± 6.3 days in the index admission cases and 3.5 ± 4.6 days after elective cases. Successful clearance was achieved at the end of the operation in 116 patients in the index admission group, clearance failed in one case and negative exploration in 5 patients. In the elective group 83 patients had a successful clearance at the end of the operation, and 2 patients has had a negative exploration. Twelve patients (index admission group) and 8 patients of the elective cases required post-operative Endoscopic Retrograde Cholangiopancreatography (ERCP) to manage retained stones, recurrent stones and bile leak (p = 0.921). Three patients required re-operation for post-operative complications in each group.

CONCLUSION

Common bile duct exploration in index admission is safe with high success rate if performed by well-trained surgeons with advanced laparoscopic skills.

Results of Medium Seventeen Years' Follow-Up after Laparoscopic Choledochotomy for Ductal Stones

Introduction. In a previously published article the authors reported the long-term follow-up results in 138 consecutive patients with gallstones and common bile duct (CBD) stones who underwent laparoscopic transverse choledochotomy (TC) with T-tube biliary drainage and laparoscopic cholecystectomy (LC). Aim of this study is to evaluate the results at up to 23 years of follow-up in the same series. Methods. One hundred twenty-one patients are the object of the present study. Patients were evaluated by clinical visit, blood assay, and abdominal ultrasound. Symptomatic patients underwent cholangio-MRI, followed by endoscopic retrograde cholangiopancreatography (ERCP) as required. Results. Out of 121 patients, 61 elderly patients died from unrelated causes. Fourteen patients were lost to follow-up. In the 46 remaining patients, ductal stone recurrence occurred in one case (2,1%) successfully managed by ERCP with endoscopic sphincterotomy. At a mean follow-up of 17.1 years no other patients showed signs of bile stasis and no patient showed any imaging evidence of CBD stricture at the site of choledochotomy. Conclusions. Laparoscopic transverse choledochotomy with routine T-tube biliary drainage during LC has proven to be safe and effective at up to 23 years of follow-up, with no evidence of CBD stricture when the procedure is performed with a correct technique.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

Between 10% to 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. Treatment of the bile duct stones can be conducted as open cholecystectomy plus open common bile duct exploration or laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy (commonest) or sphincteroplasty (papillary dilatation) for common bile duct clearance. The benefits and harms of the different approaches are not known.

OBJECTIVES

We aimed to systematically review the benefits and harms of different approaches to the management of common bile duct stones.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Issue 7 of 12, 2013) in The Cochrane Library, MEDLINE (1946 to August 2013), EMBASE (1974 to August 2013), and Science Citation Index Expanded (1900 to August 2013).

SELECTION CRITERIA

We included all randomised clinical trials which compared the results from open surgery versus endoscopic clearance and laparoscopic surgery versus endoscopic clearance for common bile duct stones.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified the trials for inclusion and independently extracted data. We calculated the odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) using both fixed-effect and random-effects models meta-analyses, performed with Review Manager 5.

MAIN RESULTS

Sixteen randomised clinical trials with a total of 1758 randomised participants fulfilled the inclusion criteria of this review. Eight trials with 737 participants compared open surgical clearance with ERCP; five trials with 621 participants compared laparoscopic clearance with pre-operative ERCP; and two trials with 166 participants compared laparoscopic clearance with postoperative ERCP. One trial with 234 participants compared LCBDE with intra-operative ERCP. There were no trials of open or LCBDE versus ERCP in people without an intact gallbladder. All trials had a high risk of bias.There was no significant difference in the mortality between open surgery versus ERCP clearance (eight trials; 733 participants; 5/371 (1%) versus 10/358 (3%) OR 0.51;95% CI 0.18 to 1.44). Neither was there a significant difference in the morbidity between open surgery versus ERCP clearance (eight trials; 733 participants; 76/371 (20%) versus 67/358 (19%) OR 1.12; 95% CI 0.77 to 1.62). Participants in the open surgery group had significantly fewer retained stones compared with the ERCP group (seven trials; 609 participants; 20/313 (6%) versus 47/296 (16%) OR 0.36; 95% CI 0.21 to 0.62), P = 0.0002.There was no significant difference in the mortality between LC + LCBDE versus pre-operative ERCP +LC (five trials; 580 participants; 2/285 (0.7%) versus 3/295 (1%) OR 0.72; 95% CI 0.12 to 4.33). Neither was there was a significant difference in the morbidity between the two groups (five trials; 580 participants; 44/285 (15%) versus 37/295 (13%) OR 1.28; 95% CI 0.80 to 2.05). There was no significant difference between the two groups in the number of participants with retained stones (five trials; 580 participants; 24/285 (8%) versus 31/295 (11%) OR 0.79; 95% CI 0.45 to 1.39).There was only one trial assessing LC + LCBDE versus LC+intra-operative ERCP including 234 participants. There was no reported mortality in either of the groups. There was no significant difference in the morbidity, retained stones, procedure failure rates between the two intervention groups.Two trials assessed LC + LCBDE versus LC+post-operative ERCP. There was no reported mortality in either of the groups. There was no significant difference in the morbidity between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 13/81 (16%) versus 12/85 (14%) OR 1.16; 95% CI 0.50 to 2.72). There was a significant difference in the retained stones between laparoscopic surgery and postoperative ERCP groups (two trials; 166 participants; 7/81 (9%) versus 21/85 (25%) OR 0.28; 95% CI 0.11 to 0.72; P = 0.008.In total, seven trials including 746 participants compared single staged LC + LCBDE versus two-staged pre-operative ERCP + LC or LC + post-operative ERCP. There was no significant difference in the mortality between single and two-stage management (seven trials; 746 participants; 2/366 versus 3/380 OR 0.72; 95% CI 0.12 to 4.33). There was no a significant difference in the morbidity (seven trials; 746 participants; 57/366 (16%) versus 49/380 (13%) OR 1.25; 95% CI 0.83 to 1.89). There were significantly fewer retained stones in the single-stage group (31/366 participants; 8%) compared with the two-stage group (52/380 participants; 14%), but the difference was not statistically significantOR 0.59; 95% CI 0.37 to 0.94).There was no significant difference in the conversion rates of LCBDE to open surgery when compared with pre-operative, intra-operative, and postoperative ERCP groups. Meta-analysis of the outcomes duration of hospital stay, quality of life, and cost of the procedures could not be performed due to lack of data.

AUTHORS' CONCLUSIONS

Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings.

Randomized clinical trial of a simple pulmonary recruitment manoeuvre to reduce pain after laparoscopy

Background

Shoulder tip and abdominal pain following laparoscopic procedures are well recognized causes of postoperative morbidity. In this double-blind randomized clinical trial attempts were made to reduce postoperative pain in patients undergoing laparoscopic surgery by implementing a simple intraoperative technique.

Methods

Patients undergoing elective laparoscopic cholecystectomy or laparoscopic transabdominal preperitoneal inguinal hernia repair were randomized to receive either the current standard treatment (control group) or an intervention to remove residual carbon dioxide. In the intervention group, the pneumoperitoneum was removed at the end of the operation by placing the patient in the Trendelenburg position and utilizing a pulmonary recruitment manoeuvre consisting of two manual inflations to a maximum pressure of 60 cmH2O. In the control group, residual pneumoperitoneum was evacuated at the end of the procedure by passive decompression via the open operative ports.

Results

Seventy-six randomly assigned patients, 37 in the intervention group and 39 in the control group, were recruited. Overall postoperative pain scores were significantly lower in the intervention group (P = 0·001). Median (interquartile range) pain scores were significantly lower in the intervention group compared with the control group at both 12 h (3·5 versus 5; P < 0·010) and 24 h (3 versus 4·5; P < 0·010).

Conclusion

Active evacuation of residual pneumoperitoneum following laparoscopic procedures, by means of two pulmonary recruitment manoeuvres in the Trendelenburg position, reduces postoperative pain significantly. This simple and safe technique can be implemented routinely after abdominal laparoscopy. Registration number: NCT01720433 (http://www.clinicaltrials.gov).

Laparoscopic transcystic exploration for single-stage management of common duct stones and acute cholecystitis

BACKGROUND

Common bile duct (CBD) stones are found in 10% of patients who undergo elective laparoscopic surgery for gallstone disease and in 10-20% of patients who present with acute cholecystitis (AC). For the latter, the role of laparoscopic transcystic exploration of the common duct (LTCE) as part of a single-stage procedure is still unknown.

METHODS

This study, based on a "laparoscopy first" policy, included 201 subjects with cholecystocholedocholithiasis: 104 underwent a scheduled laparoscopic surgery (group A), and 97 where admitted for AC and had urgent laparoscopy (group B). Group B patients were significantly older (68.4 vs. 62.1 years; P = 0.0045), had a higher proportion of women (56% vs. 41%; P = 0.0345), and included more patients in the ASA III-IV class (39% vs. 21%; P = 0.0006). LTCE was performed by using basket-wired catheters. CBD clearance, operating time, conversion rate, morbidity and mortality, postoperative hospital stay, readmission, and residual CBD stones were the main outcome measures.

RESULTS

Clearance of CBD was obtained in 84% of patients of group A and in 80% of patients of group B (P = not significant). Time spent in the operating room was longer for group B (175 vs. 141 min; P = 0.0003). There were no significant differences for postoperative hospital stay (group A 4.9 vs. group B 5.2 days), readmission rate (3.7% vs. 3.7%), and residual CBD stones (2.8% vs. 3.1%). Need to convert and morbidity occurred more frequently in group B (11.7% vs. 4.6% and 28.7% vs. 16.8%, respectively), but differences were not significant. In group A, one patient died from MOFS.

CONCLUSIONS

LTCE has proved to be a simple technique with a high yield of CBD clearance in the acute setting. Courses are comparable to those observed for the same procedure in elective surgery despite the fact that patients with AC are more at risk for drawbacks.

Comparison of long-term results of laparoscopic and endoscopic exploration of common bile duct

Background:

To compare long term results of laparoscopic and endoscopic exploration of common bile duct, to assess post-procedure quality of life.

Materials and Methods:

From September 1992 to August 2003, we performed 4058 cholecystectomies, out of which 479 (11.80%) patients had choledocholithiasis. There were 163 males and 316 females. Mean age was 63.65 ± 5.5 years. These patients were put in two groups. In the first group of 240 patients, a majority of patients underwent two-stage procedures. ERCP/ES was performed in 210 (87.50%) cases. In the second group of 239 patients, a majority of patients underwent single-stage procedures. ERCP/ES was done in 32 (13.38%) cases.

Results:

Mortality was zero in both groups. Morbidity was 15.1% in first group and 7.5% in second group. Mean hospital stay was 11.7 ± 3.2 days in first group and 6.2 ± 2.1 days in second group. Average operative time was 95.6 ± 20 minutes in first group and 128.4 ± 32 minutes in second group. Completed questionnaires received from 400 (83.50%) patients revealed better long-term results in the second group. Clinical features of low-grade cholangitis were seen in 20% of patients who underwent ES. Hence the post-procedure quality of life in patients who underwent single-stage procedures was definitely much better, because of minimal damage of sphincter of Oddi.

Conclusions:

Single-stage laparoscopic operations provide better results and shorter hospital stay. Damage to sphincter of Oddi should be minimal, to avoid long-term low-grade cholangitis. In young patients, the operation of choice should be single-stage laparoscopic procedure with absolutely no damage to sphincter of Oddi.

A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis

INTRODUCTION

Outcomes after endoscopic sphincterotomy (ES) and subsequent laparoscopic cholecystectomy (LC) versus laparoscopic bile duct exploration (LBDE) during LC are comparable in fit patients with choledocholithiasis. This randomized, clinical trial aimed to determine the optimum treatment in patients with higher medical risk.

MATERIALS AND METHODS

Ninety-one higher risk patients with evidence of bile duct stones were randomized to ES/LC (group A) or LBDE during LC (group B). The primary outcome measure was duct clearance. Secondary outcome measures were complications, number of procedures per patient, conversion, and postoperative hospital stay (POS).

RESULTS

Forty-seven patients were randomized to ES/LC and 44 to LBDE. The median age was 74.56 years. On an intention-to-treat basis, duct clearance was achieved in 29 of 47 of group A and 44 of 44 of Group B patients (P < 0.001). Clavien Grade II-V complications occurred in 8 of 47 and 8 of 44 patients (P = 0.884), the median number of procedures was 2 (2-3) and 1 (1-1) (P < 0.001), 2 of 47 and 4 of 44 patients required conversion (P = 0.676), and the median POS was 3 (2-7) and 5 (2-7) days (P = 0.825), respectively.

CONCLUSIONS

There was no difference between approaches to duct clearance in terms of postoperative stay, complications, or conversion in higher risk patients, but the laparoscopic approach was more effective and efficient and avoided unnecessary procedures.

Cholangiopancreatoscopy: a comprehensive review

Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.

Efficacy and safety of early laparoscopic common bile duct exploration as primary procedure in acute cholangitis caused by common bile duct stones

INTRODUCTION

The elective laparoscopic management of common bile duct (CBD) stones is widely accepted; however, the urgent laparoscopic exploration of common bile duct (LCBDE) within the first 72 hours of acute cholangitis is not assessed extensively. Our aim was to study the safety and efficacy of urgent LCBDE in patients with acute cholangitis.

MATERIALS AND METHODS

In a single-center prospective study, 73 patients of a university hospital with acute gallstone cholangitis were operated on with laparoscopy or open surgery, based on a predetermined schedule concerning the presence of the skilled laparoscopic surgeon at the hospital. Patients with sever acute cholangitis (e.g., organ failure, shock, or peritonitis), pancreatitis, and suspected tumoral obstructions were excluded. The major outcomes, including mortality, complications of surgery, and the length of hospital and intensive care unit (ICU) stay, are reported in this paper.

RESULTS

In all 36 open surgery patients, a choledocotomy and T-tube placement procedure were performed. In laparoscopic patients, CBD clearance was approached by a transcystic and choledocotomy approach in 15 and 22 subjects, respectively. Eight (6 in the open and 2 in the laparoscopic group) choledocoduodenostomies were performed. Cholangitis was controlled sufficiently in all patients. Of 37 laparoscopies, 3 operations were converted into open surgeries. Operation time was longer in the laparoscopic group, compared to the open group (201 +/- 15 vs. 146 +/- 6.1 minutes; P < 0.01). The average ICU and hospital stay after an operation were significantly less than open surgery group. Total cost of treatment in laparoscopic group was less than 75% of that of the open surgery group. General complications were more common in the open surgery group. There was no mortality. One retained stone was discovered in the laparoscopic group.

CONCLUSIONS

Early one-stage LCBDE is an effective procedure as an initial and definite management of acute gallstone cholangitis, which prevents a second hospitalization and relapse problems.

An Economic Analysis of Hospital Charges for Choledocholithiasis by Different Treatment Strategies

The ideal management of presumed choledocholithiasis is controversial. We hypothesized that patients admitted with presumed choledocholithiasis would be better served financially to undergo laparoscopic cholecystectomy (LC) with possible intraoperative intervention versus preoperative endoscopic retrograde cholangiopancreatography followed by LC. A chart review was performed from September 1, 2000 to August 31, 2003. One hundred seventy-one consecutive patients identified with presumed choledocholithiasis were reviewed. Six patients were excluded because of missing charge data. Professional and technical fees from the total hospital charges were used for comparison. Three groups of patients were compared for charge analysis. Group 1 underwent LC with laparoscopic common bile duct exploration. Group 2 underwent LC with preoperative or postoperative endoscopic retrograde cholangiopancreatography. Group 3 was a control group of LC only. Student's t test was used for statistical analysis with a P value of <0.05 defined as statistically significant. P values reflect comparisons with Group 1. Group 1 charges were $13,026, Group 2 charges were $15,303, and Group 3 charges were $9,122. For suspected choledocholithiasis, LC with intraoperative intervention is the most economically advantageous approach.

Thirteen years' experience with laparoscopic transcystic common bile duct exploration for stones. Effectiveness and long-term results

BACKGROUND

The aim of the present study was to evaluate the effectiveness and long-term results of laparoscopic transcystic common bile duct exploration (TC-CBDE).

METHODS

Ductal stones were present in 344 of 3212 patients (10.7%) who underwent laparoscopic cholecystectomy (LC). The procedure was completed laparoscopically in 329 patients (95.6%), with TC-CBDE performed in 191 patients (58.1%) who are the object of this study, or with a transverse choledochotomy in 138 cases (41.9%).

RESULTS

Biliary drainage was employed in 71 of 191 cases (37.2%). Major complications occurred in 10 patients (5.1%), including retained stones in 6 (3.1%). Mortality was nil. No patients were lost to follow-up (median: 118.0 months; range: 17.6-168 months). No signs of bile stasis, no recurrent ductal stones and no biliary stricture were observed. At present 182 patients are alive with no biliary symptoms; 9 have died from unrelated causes.

CONCLUSIONS

Long-term follow-up after laparoscopic TC-CBDE proved its effectiveness and safety for single-stage management of gallstones and common bile duct stones.

Surgical versus endoscopic treatment of bile duct stones

BACKGROUND

10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.

OBJECTIVES

To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy.

SEARCH STRATEGY

We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.

SELECTION CRITERIA

The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.

DATA COLLECTION AND ANALYSIS

Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.

MAIN RESULTS

Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.

AUTHORS' CONCLUSIONS

In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.

Laparoscopic transcystic duct common bile duct exploration

The modern era of common bile duct (CBD) surgery started with Mirizzi, who introduced intraoperative cholangiography in 1932. Intraoperative choledoscopy had been developed as an adjunctive to intraoperative cholangiography, which helped to detect CBD stones in an additional 10% to 15% of instances that otherwise would have been missed. Findings have shown choledochoscopy to be an important technique for efficient and effective management of CBD stones. Efforts to treat patients with common duct stones in one session and to avoid the potential complications of endoscopic sphincterotomy resulted in several laparoscopic transcystic CBD (LTCBDE) techniques. The techniques of transcystic stone extraction include lavage, trolling with wire baskets or biliary balloon catheters, cystic duct dilation, biliary endoscopy, and stone retrieval with wire baskets under direct vision and antegrade sphincterotomy, lithotripsy, and catheter techniques. The indications for LTCBDE are filling or equivocal defects at cholangiography, stones smaller than 10 mm, fewer than 9 stones, and possible tumor. The contraindications are stones larger than 1 cm, stones proximal to the cystic duct entrance into the CBD, small friable cystic duct, and 10 or more stones. Experience with LTCBDE shows that the approach is applicable in more than 85% of cases, with a success rate of 85% to 95%. It also is shown to be more cost effective than postoperative endoscopic retrograde cholangiopancreatography. Recent developments in LTCBDE have focused mainly on implementation of robotically assisted surgery and new imaging methods such as magnetic resonance cholangiopancreatography with three-dimensional virtual cholangioscopy and three-dimensional ultrasound. Further technological advances will facilitate the application of laparoscopic approaches to the common duct, which should become the primary strategy for the great majority of patients.

Management of common bile duct stones in a rural area of the United States

BACKGROUND

Laparoscopic common bile duct exploration has been reported to be highly successful and cost-effective. It remains unknown to what extent the procedure is used in routine surgical practice.

METHODS

We conducted a survey of general surgeons practicing in a rural area of the United States. The type of practice, laparoscopic training, performance of cholangiography, and preferred approach to choledocholithiasis were elicited.

RESULTS

Sixty-eight of 207 surveys (33%) were returned. Thirty respondents (45%) indicated that they perform laparoscopic common bile duct explorations. The likelihood of laparoscopic common bile duct exploration increased with a higher number of cholecystectomies per year (p < 0.05, chi-square) but was independent of training or routine cholangiography. The preferred approach to a patient with choledocholithiasis was endoscopic retrograde cholangiopancreatography (75%), followed by laparoscopic (21%) and open exploration (4%). Reasons for not performing laparoscopic exploration were time (58%), equipment (24%), good gastrointestinal backup (6%), reimbursement (3%), increased morbidity (1.5%), lack of skill (1.5%), and other/no reason (18%).

CONCLUSION

Although 45% of practicing surgeons indicated that they perform laparoscopic common bile duct explorations, only 21% practiced it as their preferred approach. Time constraints and lack of equipment are the main factors preventing the application of the laparoscopic technique toward choledocholithiasis.

Laparoscopic common bile duct exploration with T-tube choledochotomy for the management of choledocholithiasis

Although laparoscopic cholecystectomy (LC) has become the gold standard for the management of gallstone disease, the application of laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has been slower. The aim of this study is to determine the feasibility and effectiveness of LCBDE. A retrospective cohort study was conducted to compare LCBDE (n = 82) with conventional common bile duct exploration (CCBDE) (n = 75) and endoscopic sphincterotomy (EST) (n = 80) in the management of choledocholithiasis. All our LCBDEs were performed through choledochotomy with T-tube placement. The mean operative time of the LCBDE group (124 +/- 48 minutes) was not significantly longer then the CCBDE group (118 +/- 35 minutes), while the postoperative hospitalization was shorter in both the LCBDE (8 +/- 5 days) and EST (9 +/- 4 days) groups than in the CCBDE (13 +/- 6 days) group. In the LCBDE group, 14 patients (17.1%) required postoperative choledochoscopy to clear residual stones through the T-tube tract. The only mortality occurred in the CCBDE group. The morbidity rate was 3.7% (3/82) in the LCBDE group, including bile leakage in 1 case and bile peritonitis in 2 cases; 6.7% (5/75) in the CCBDE group, including atlectasis in 2 cases, sepsis in 1, and wound infection in 2. There were 2 cases of postoperative pancreatitis (2.5%; 2/80) in the EST group. The difference in the average number of sessions needed for complete clearance of choledocholithiasis in each group was statistically significant (EST, 1.46 +/- 0.67; LCBDE, 1.23 +/- 0.42; and CCBDE, 1.09 +/- 0.28; P < 0.0001). Our results suggested that EST and LCBDE tended to require more therapeutic sessions then CCBDE, although these sessions were less invasive. The benefits of LCBDE include minimal invasiveness, concurrent treatment of gallbladder stone and CBD stones in a single session, and a shorter postoperative hospital stay. However a longer learning curve is needed. Selection of the most suitable therapeutic option for individual patients by an experienced surgeon gives the most benefits to patients.

Long-term results after laparoscopic transverse choledochotomy for common bile duct stones

BACKGROUND

The aim of this study was to evaluate the long-term results of laparoscopic transverse choledochotomy (TC) during laparoscopic cholecystectomy (LC).

METHODS

Ductal stones were present in 344 of 3,212 patients (10.7%) who underwent LC. The procedure was completed laparoscopically in 329 cases (95.6%), with a TC in 138 cases (41.9%) (the subjects of this study), and with a transcystic duct approach in 191 cases (58.1%).

RESULTS

Biliary drainage was used in 131 of 138 cases (94.9%). There were major complications in eight patients (5.7%), and one patient died (0.7%). Retained stones were seen in 11 cases (8%). None of the patients was lost to follow-up (mean, 72.3 months; range, 11-145). Ductal stones recurred in five patients (3.6%). No signs of bile stasis and no biliary strictures were observed. In all, 121 patients are alive with no biliary symptoms; 16 have died from unrelated causes.

CONCLUSION

Long-term follow-up after laparoscopic TC during LC proved its safety and efficacy.

A stone extraction facilitation device to achieve an improved technique for performing LCBDE

BACKGROUND

Laparoscopic common bile duct exploration (LCBDE) has proved to be a safe, cost-effective way to treat common bile duct (CBD) stones. Despite this, LCBDE has not gained widespread adoption by surgeons. The technique has proved difficult to master, and damage to the fragile choledochoscope by grasping forceps and passage through the port valves has been problematic. Cases involving large, impacted, or multiple stones have required conversion to open exploration of CBD.

METHODS

The Multichannel Instrument Guide (MIG) is introduced as a solution for these problems. The MIG is a J-shaped plastic extrusion with three lumens. It is flexible and can be straightened for insertion through a 10-mm port. The MIG facilitates insertion of a flexible 2.8- to 3.2-mm choledochoscope into the CBD. At the same time, additional tools such as balloon or irrigation catheters and lithotripters can be introduced into the CBD. These can be manipulated under video guidance via the choledochoscope. This procedural multitasking allows for a more efficient LCBDE. The authors describe their initial experience using the MIG for 23 patients.

RESULTS

Of the 23 patients who underwent LCBDE procedures, 20 had stones in the CBD. Multiple stones were present in 48% of the patients; impacted stones were present in 26% of the patients; and stones larger than 1 cm were present in 26% of the patients. A 95% stone clearance rate was achieved. Difficult cases with large, impacted or multiple stones were resolved using the MIG. Two choledochoscopes were damaged; one during surgery and one during cleaning and storage.

CONCLUSIONS

The MIG has demonstrated significant advantages over previously described techniques. The device secures biliary tract access and allows procedural multitasking while protecting the delicate and expensive equipment. Subsequently, a simplified technique algorithm can be followed that may encourage more surgeons to adopt the routine performance of LCBDE.

Symptoms before and after Laparoscopic Cholecystectomy for Gallstones

Between 1989 and 1995, 1380 patients underwent laparoscopic cholecystectomy for symptomatic cholelithiasis by a single surgical group at a large private teaching hospital. Thirteen hundred surveys were mailed, and 573 (44.3%) were completed at least 6 months postoperatively. Pain and nonpain symptoms were present preoperatively in 432 (75%) and 457 (80%) patients, respectively. Postoperatively, pain and nonpain symptoms were present in 141 (25%) and 247 (43%) patients, respectively ( P < 0.05). All nonpain symptoms were significantly reduced postoperatively except for diarrhea ( P < 0.05). Longer duration of pain, age < 40, frequent episodes of pain, postprandial pain, and increased sites of pain preoperatively were all predictive of a higher incidence of persistent postoperative pain ( P < 0.05). Persistent nonpain symptoms were more likely if diarrhea, fatty food intolerance, age < 40, or both pain and nonpain symptoms were present preoperatively ( P = 0.05) and less likely if only pain symptoms were present preoperatively ( P = 0.0001). This series quantifies symptom-specific outcomes for the surgeon. While most symptoms improve, a significant number of pain and nonpain symptoms persist after laparoscopic cholecystectomy. With these data, surgeons can modulate postoperative expectations and advise on the possible persistence of symptoms.

Long-term results from laparoscopic common bile duct exploration

BACKGROUND

The aim of this study was to evaluate the long-term results after laparoscopic common bile duct exploration (LCBDE).

METHODS

A retrospective review of 175 consecutive patients who underwent attempted LCBDE between 1992 and 1999 was conducted. Laparoscopic transcystic exploration was accomplished in 110 patients and laparoscopic choledochotomy in 52 patients. Conversion to an open common bile duct exploration was required for 13 patients (7.4%). Retained common bile duct stones occurred in eight patients (4.6%). The 30-day postoperative morbidity was 6.9%, and there was no 30-day mortality. All the patients (alive and localized) received a questionnaire evaluating long-term results.

RESULTS

Of the 175 patients, 169 (4 unrelated deaths and 2 patients lost to follow-up evaluation) received and 152 (90%) returned the questionnaire. The follow-up period ranged from 6 to 72 months (median, 36 months). One patient developed recurrent common bile duct stones. There were no signs or evidence of common bile duct stricture in any patient.

CONCLUSION

The LCBDE procedure can be performed without increased risk of late bile duct complications.

Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct

BACKGROUND

Laparoscopic exploration of the common bile duct is becoming more popular, although endoscopic sphincterotomy remains the usual treatment for bile duct stones. However, loss of the biliary sphincter causes permanent duodenobiliary reflux, and recurrent stone disease and biliary neoplasia may be a consequence.

METHODS

A systematic literature review was conducted to compare laparoscopic exploration with endoscopic sphincterotomy. A text word search of the Medline, Pubmed and Cochrane databases, and a manual search of the citations from these references, was used.

RESULTS

Endoscopic sphincterotomy is associated with a median (range) mortality rate of 1 (0-6) per cent, compared with 1 (0-5) per cent for laparoscopic bile duct exploration. The median (range) rate of pancreatitis following endoscopic sphincterotomy is 3 (1-19) per cent; this is a rare complication after laparoscopic duct exploration. The combined morbidity rate for laparoscopic cholecystectomy and endoscopic sphincterotomy is 13 (3-16) per cent, which is greater than 8 (2-17) per cent for laparoscopic bile duct exploration. Randomized trials are few and contain relatively small numbers of patients. They show little overall difference in rates of duct clearance, but a higher mortality rate and number of hospital admissions are noted for endoscopic sphincterotomy compared with laparoscopic bile duct exploration. Endoscopic sphincterotomy is associated with recurrent stone formation (up to 16 per cent) with associated cholangitis. It is also associated with bacterobilia and chronic mucosal inflammation. The late development of bile duct cancer has been reported in up to 2 per cent of patients.

CONCLUSION

Laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy plus laparoscopic cholecystectomy. :

Preoperative selective endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy without cholangiography

The aim of this study was to show that laparoscopic cholecystectomy can be performed safely without routine intraoperative cholangiography. We performed a retrospective analysis of 1750 consecutive patients (1170 females and 580 males with a mean age of 51 years) who underwent laparoscopic cholecystectomy between January 1991 and January 2000. In all, 193 patients (11%) were selected to undergo preoperative endoscopic retrograde cholangiopancreatography (ERCP) on the basis of several criteria for risk of stones. No patients underwent intraoperative cholangiography. ERCP allowed us to make a diagnosis of biliary stones in 62.7% (121 cases). Extraction of the stones was successful in 96% of the cases. In 12% of cases ERCP findings were normal; in the remaining 26.3%, useful diagnostic information was obtained. There were three complications (bleeding and pancreatitis) after endoscopy (complication rate: 1.5%). Laparoscopic cholecystectomy was successful in 92.7% of patients, with a postoperative morbidity rate of 3% (0.5% of major complications). There were no deaths in this series. During a mean follow-up of 60 months (range, 12-120), 7 patients (0.43%) were found to have residual biliary stones (5 had not had preoperative ERCP). The study confirms the hypothesis that laparoscopic cholecystectomy can be safely performed without routine intraoperative cholangiography, with selective use of preoperative ERCP.

Dynamic MR Cholangiography after Fatty Meal Loading: Cystic Contractility and Dynamic Evaluation of Biliary Stasis

PURPOSE

Dynamic MR cholangiography was conducted on patients with cholelithiasis or choledocholithiasis who had consumed a fatty test meal (Molyork) and the cystic contractility and dynamics of biliary stasis was evaluated.

SUBJECTS AND METHOD

The subjects were 25 with intracystic cholelithiasis, 10 with choledocholithiasis and 10 normal controls. For an imaging sequence, the rapid acquisition with relaxation enhancement (RARE) method was employed and imaging was conducted for 40 min (every 30 s following Molyork administration) without breath-holding. The gallbladder contraction ratio was computed and the contractile ratio for the common bile duct was calculated. To determine the bile flow to the duodenum, the high-intensity signal, indicating the flow from the lower common bile duct, and perfusion of the duodenum were observed in dynamic mode on the monitor with the naked eye and interpreted as positive bile flow. The frequency of this flow was visually monitored.

RESULTS

The gallbladder contractile ratio was significantly reduced in patients with cholelithiasis or choledocholithiasis compared with the controls. In a comparison with the normal controls, no sequential changes were noted in the mean contractile ratio of the common bile duct of the patients with cholelithiasis or choledocholithiasis. The mean frequency of bile flow observed for each 40 min period was 13+/-2.4, 6+/-2.2, and 4+/-1.3 times for the controls, those with intracystic cholelithiasis, and those with choledocholithiasis, respectively. Compared with the controls, the latter two patient groups showed evident reductions in the frequency of bile flow to the duodenum (p<0.001).

CONCLUSION

Dynamic MRC combined with Molyork loading makes it possible to compute cystic contractile ratios and perform a dynamic examination of bile flow under non-invasive, near-physiological conditions.

Is intraoperative cholangiography during laparoscopic cholecystectomy cost effective?

BACKGROUND

Common bile duct injuries occur in 0.2% to 0.8% of laparoscopic cholecystectomies (LC). Intraoperative cholangiograms (IOCG) are a useful means of detecting common bile duct injuries in the operating room.

METHODS

Data were retrospectively reviewed for patients referred for management of common duct injuries from 1996 to 2000. Cost data were obtained from hospital records. Legal settlements were obtained from published sources.

RESULTS

Twenty-one patients (0.133%) were found to have bile duct injuries and incurred median hospital stays of 11.5 days at an average cost of $587,491. The average cost of those requiring reoperation was $669,134. The 21 cases in our sample had total charges of $10,819,767. Performing IOCG during each LC in Orange County would have cost $10,669,725. If extrapolated to state and nationwide levels, the savings is far greater.

CONCLUSIONS

IOCG during LC is a cost-effective means of preventing the costs of delayed recognition of bile duct injuries.

Laparoscopic cholecystectomy in the new millennium

BACKGROUND

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

METHODS

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

RESULTS

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

CONCLUSIONS

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.

A balanced approach to choledocholithiasis

BACKGROUND

We set out to review and evaluate the results of an algorithm for managing choledocholithiasis in patients undergoing laparoscopic cholecystectomy.

METHODS

We performed retrospective review of patients with choledocholithiasis at the time of laparoscopic cholecystectomy (LC) between March 1993 and August 1999. All patients were operated on under the direction of one surgeon (M.E.A), following a consistent algorithm that relies primarily on laparoscopic transcystic common bile duct exploration (TCCBDE) but uses laparoscopic choledochotomy (LCD) when the duct and stones are large or if the ductal anatomy is suboptimal for TCCBDE. Intraoperative endoscopic retrograde sphincterotomy (ERS) is done if sphincterotomy is required to facilitate common bile duct exploration (CBDE). Postoperative endoscopic retrograde cholangiopancreatography (ERCP) is utilized when this fails. Preoperative ERCP is used only for high-risk patients.

RESULTS

A total of 728 LC were performed, and there were 60 instances (8.2%) of choledocholithiasis. Primary procedures consisted of 47 TCCBDE; 37 of them required no other treatment. In five cases, the stones were flushed with no exploration. Intraoperative ERS was performed three times as the only form of duct exploration. LCD was utilized twice; one case also required intraoperative ERS, and the other had a postoperative ERCP for stent removal. One patient with small stones was observed, with no sequelae. Preoperative ERCP was done twice as the primary procedure. Of the 10 cases that were not completely cleared by TCCBDE, three had a postoperative ERCP and seven had an intraoperative ERS, one of which required a postoperative ERCP. There were three complications (6%) related to CBDE, with no long-term sequelae. There were four postoperative complications (6.7%) and no deaths. The mean number of procedures per patient was 1.12. The average postoperative hospital stay was 1.8 days (range, 0-14).

CONCLUSIONS

Choledocholithiasis can be managed safely by laparoscopic techniques, augmenting with ERCP as necessary. This protocol minimizes the number of procedures and decreases the hospital stay.

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.