Prediction and Management of Choledocholithiasis in Patients Undergoing Laparoscopic Cholecystectomy due to Cholelithiasis

Lee, Jung Yong; Hur, Byung Won; Jung, Gil Man; Kim, Jae Seon; Byun, Kwan Soo; Choi, Sang Yong; Bak, Young Tae; Kim, Jin Ho; Kim, Jong Guk

Abstract

BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography(ERCP) or operative cholangiography is the procedure to demonstrate and remove stones of the biliary tree in patients undergoing laparoscopic cholecystectomy(LC) due to cholelithiasis. However, ERCP or operative cholangiography is an invasive procedure. The next question then is when and for what indication should ERCP or operative cholangiography be performed. The aims of this study were to assess whether prediction of common bile duct(CBD) stones by the noninvasive method such as liver function test and/or clinical findings is possible, and to investigate which method is more adequate for removal of CBD stones found on ERCP or operative cholangiography.
METHODS
A total 207 patients with symptomatic cholelithiasis scheduled for LC were enrolled from September 1993 to August 1996. Patients who were already found to have either extrahepatic or intrahepatic biliary stones on sonogram were excluded. Patients were classified into risk group and non-risk group. Patients who belong to the risk group were those having CBD dilatation by ultrasonography, history of jaundice or cholangitis, gallstone pancreatitis, or elevated transaminases.
RESULTS
54 cases were confirmed to have CBD stones by preoperative ERCP(49 cases) and operative cholangiography(5 cases). Detection rate of CBD stones in risk group was 26.8%(22.2% in CBD dilatation, 50.0% in jaundice, 42.9% in history of cholangitis, and 0% in history gallstone pancreatitis or elevated transaminase). Detection rate of CBD stones in non-risk group was 7.7%. All of 12 patients who had CBD stones were successfully removed(10 with preoperative endoscopic removal, 1 with postoperative endoscopic removal, and 1 with CBD exploration).
CONCLUSIONS
Jaundice or cholangitis need the preoperative ERCP and, if stones are found, they can be revoved endoscopically. CBD dilatation may be an indication for operative cholangiography rather than preoperative ERCP, and, if CBD stones were found, they can be revoved by laparoscopic CBD exploration or postoperative ERCP. But history of gallstone pancreatitis, elevated transaminases, or patients with no risk factors may not need preoperative ERCP or operative cholangiography considering the cost-effectiveness or possible morbidity.