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com/esps/ World J Gastrointest Endosc 2014 February 16; 6(2): 32-40

[email protected] ISSN 1948-5190 (online)
doi:10.4253/wjge.v6.i2.32 © 2014 Baishideng Publishing Group Co., Limited. All rights reserved.

REVIEW

Modern approach to cholecysto-choledocholithiasis

Lapo Bencini, Cinzia Tommasi, Roberto Manetti, Marco Farsi

Lapo Bencini, Cinzia Tommasi, Marco Farsi, Division of Sur- ture. Therefore, the choice of the best management is
gical Oncology, Department of Oncology, Azienda Ospedaliero- often led by the local presence of professional expertise
Universitaria di Careggi, 50131 Florence, Italy and resources, rather than by a real superiority of one
Roberto Manetti, Unit of Surgical Endoscopy, Department of strategy over another.
Medicine and Emergencies, Azienda Ospedaliero-Universitaria di
Careggi, 50131 Florence, Italy © 2014 Baishideng Publishing Group Co., Limited. All rights
Author contributions: Bencini L ideated and designed the re-
reserved.
search, as well as performed bibliographic research; Bencini L,
Manetti R, Tommasi C and Farsi M also performed the research
and contributed to the final draft of this paper; all the authors Key words: Laparoscopy; Endoscopy; Laparo-endoscop-
contributed substantially to this work. ic; Endoscopic retrograde cholangiography; Bile duct
Correspondence to: Lapo Bencini, MD, PhD, Division of Sur- stones; Cholecystolithiasis; Common bile duct stones;
gical Oncology, Department of Oncology, Azienda Ospedaliero- Laparoendoscopic rendezvous
Universitaria di Careggi, Largo Brambilla 3, 50131 Florence,
Italy. [email protected] Core tip: There is no consensus on the correct strategy
Telephone: +39-55-7947404 Fax: +39-55-7947451 for the care of simultaneous gallbladder and common
Received: November 16, 2013 Revised: January 1, 2014 bile duct stones. Many therapeutic options are avail-
Accepted: January 15, 2014
able, including laparoscopic, endoscopic, percutaneous
Published online: February 16, 2014
and open traditional techniques, either through a com-
bination of these treatments or by conducting them in
a stepwise sequence.

Abstract
Gallstones and common bile duct calculi are found to Bencini L, Tommasi C, Manetti R, Farsi M. Modern approa-
be associated in 8%-20% of patients, leading to pos- ch to cholecysto-choledocholithiasis. World J Gastrointest
sible life-threatening complications, such as acute bili- Endosc 2014; 6(2): 32-40 Available from: URL: http://www.
ary pancreatitis, jaundice and cholangitis. The gold wjgnet.com/1948-5190/full/v6/i2/32.htm DOI: http://dx.doi.
standard of care for gallbladder calculi and isolated org/10.4253/wjge.v6.i2.32
common bile duct stones is represented by laparo-
scopic cholecystectomy and endoscopic retrograde
cholangiopancreatography, respectively, while a debate
still exists regarding how to treat the two diseases at INTRODUCTION
the same time. Many therapeutic options are also avail-
able when the two conditions are associated, including
Common bile duct stones (CBDS) occur in 8%-20%[1,2]
many different types of treatment, which local profes- of patients suffering from gallstones, although actual in-
sionals often administer. The need to limit maximum cidences of CBDS in this patient group could be higher.
discomfort and risks for the patients, combined with The association of these two conditions can lead to many
the economic pressure of reducing costs and utilizing severe complications, such as acute biliary pancreatitis,
resources, favors single-step procedures. However, a jaundice and cholangitis, transforming the choice of the
multitude of data fail to strongly demonstrate the supe- best strategy for treating a benign issue into a potentially
riority of any technique (including a two or multi-step life-threatening problem. Although some authors have
approach), while rigorous clinical trials that include so advocated for a “wait and see” policy for asymptomatic
many different types of treatment are still lacking, and gallbladder stones[3], almost none could propose the same
it is most likely unrealistic to conduct them in the fu- approach if CBDS are detected as well[2,4]. Nonetheless, a

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 Bencini L et al . Cholecysto-choledocholithiasis

significant paper also reported a conservative (no action) means of an intraoperative route (injecting the contrast
behavior for silent CBDS found during routine intraop- medium through the cystic or the common bile duct), by
erative cholangiogram (IOC)[5]. Moreover, in the case of an endoscopic papillary injection or even by a percutane-
patients with severe comorbidity unfit for surgery and ous approach. All methods are, of course, invasive.
symptoms of CBD obstruction (jaundice, cholangitis, re- Since the advent of laparoscopy, the preoperative
current acute pancreatitis), the sole execution of a formal diagnosis of CBDS has become increasingly popular due
endoscopic retrograde cholangiography (ERCP) is often to the need for avoiding laparoscopic IOC and further
obligatory, leaving the gallbladder in situ[6]. However, a treatments that were, at the beginning of the experience,
Cochrane review failed to confirm the imperative neces- highly demanding. Moreover, the widespread adoption
sity of an immediate ERCP to relieve acute pancreatitis of ERCP, even as a diagnostic tool, enormously impacted
without sepsis[7]. A very intriguing observational study the development of some excessively invasive algorithms
from Sweden[8] reported a so-called “paradigm shift” due to success rates of CBD clearance of almost 98% in
from open choledochotomy and cholecystectomy toward the hands of experienced endoscopists[19].
bile duct clearance using the endoscopic route and selec- Currently, IOC is routinely performed in some cen-
tive laparoscopic cholecystectomy in patients suffering ters[20-22] and selectively in others[23,24], while it is easily
from cholecysto-choledocholithiasis (CCL). reproducible by the majority of surgeons. Nevertheless,
While the “gold standard” of treatment for gallstones the definitive acceptance of one policy over another
has been laparoscopic cholecystectomy (LC) since the has not been confirmed[25], with selective IOC having
early 1990s[9,10] and ERCP is considered optimal for iso- some advantages in terms of a shorter operating time
lated CBDS[4], no consensus exists to address CCL[11,12]. and fewer perioperative complications but at the price
The European Association for Endoscopic Surgery pub- ofa higher readmission rate if CBDS are subsequently
lished the comprehensive guidelines of minimally inva- detected[22]. Moreover, laparoscopic CBD exploration is
sive approaches in 2006, but no robust statements were becoming more popular, while intraoperative or postop-
published regarding the best treatment for CCL[13]. erative ERCP is also safe and effective. However, current
Many therapeutic options are available, including lapa- good practice should reserve the use of ERCP for those
roscopic, endoscopic, percutaneous and open traditional patients with CBDS as a therapeutic strategy only in se-
techniques, either as a combination in a concurrent man- lected doubtful cases[18] due to the possibility of compli-
ner or as a stepwise sequence. cations[26-28] and false-positives.
The choice of the best strategy is often led by the Many of the diagnostic flow-charts and algorithms
local presence of professional expertise and resources, proposed consider a baseline stratification of the risk of
rather than by a real superiority of one strategy over an- having CBDS, including ultrasonography dilatation of
other[12,14-18]. the CBD and biochemical parameters, such as gamma-
However, the current standard of treatment for CCL glutamyl transpeptidase, transaminases, alkaline phos-
is influenced by many different professionals, including phatase, bilirubin and lactatedehydrogenase. All of these
gastroenterologists, anesthesiologists, surgeons and en- markers are combined in predictive models[16,29] to reserve
doscopists, leading to some conflict regarding organizing more invasive or expensive imaging - cholangiography
approaches for treatment. by ERCP or IOC, magnetic resonance cholangiography
We performed a PubMed, Embase and Cochrane (MRC) and endoscopic ultrasonography (EUS) - for
bibliographic search for CCL, updated in October 2013, higher-risk patients, although no clinical-laboratory pa-
by manually searching for interesting cross-matched ref- rameter is able to predict CBDS with optimal accuracy[30].
erences. Reporting on more recent articles, randomized Currently, the most important preoperative diagnostic
clinical trials (RCTs) and meta-analyses was considered tools are MRC and the traditional ultrasound[31-35]. Alter-
a priority. Intrahepatic bile duct stones represent a less natively, the policy of routine MRC was not found to be
common disease with several peculiar pathological eti- cost-effective in patients without symptoms or suspicion
ologies and will not be considered further in this review. of CBDS, whereas IOC during LC was the best strat-
Despite some differences in the epidemiologic features egy[36]. Interestingly, some authors reported[37] the routine
of gallstones and CCL, a special effort was made to in- use of IOC during LC, even after MRC and successful
clude papers published from all over the world, including preoperative ERCP, to detect residual CBDS. Indeed, due
North America, Europe and Asia.
to the higher sensibility of IOC over MRC, it could be
hypothesized that there is no need to conduct preopera-
DIAGNOSIS OF COMMON BILE DUCT tive MRC in those patients suspected to have CBDS who
are already scheduled for an intervention[38].
STONES Recently, introducing EUS added a new tool to the di-
The first crucial issue for correctly managing CCL is to agnostic algorithm of CDS. Despite the relatively scarce
reach a good diagnosis in order to reduce unplanned use of this technique among many hospitals worldwide,
procedures, unnecessary invasive exams and under treat- its routine use, at least in patients with intermediate and
ment. Traditionally, the gold standard of diagnosis is high risk of CBDS[39-42], could play an important role for
achieved by cholangiography, which can be conducted by the next future two-stage strategy. A proposed rational

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 Bencini L et al . Cholecysto-choledocholithiasis

sequence could reserve EUS for those patients with in- Postoperative ERCP (after laparoscopic
termediate to high risk of CBDS and a negative MRC[43]. cholecystectomy)
A realistic and intriguing new proposal could consider the In those patients with a lower risk of CBDS, a policy
adoption of EUS in selected patients suspected to have of selective IOC and ERCP after LC seems to be ratio-
CBDS, followed by a consecutive session of ERCP[44]. nal[50]. Similar situations are represented by intraoperative
The role of the CT scan in detecting CBDS is quite diagnosis of CBDS when an endoscopist or a surgeon
marginal, and its use is limited by the low frequency of trained to perform a laparoscopic bile duct clearance is
radiopaque stones and cut-off size[45]. However, it may be not available in the operating theatre or in those cases of
useful when a silent incidental stone is found. misdiagnosed CBDS discovered only after LC. Obviously,
two anesthesiologic sessions are needed, which are likely
to disturb the patient. Lastly, the main risk of such an ap-
CCL proach is to fail a complete bile duct clearance postopera-
There are many options to treat CCL, but each one has tively and to then have to conduct further procedures[51].
different advantages and limitations. Few trials have
demonstrated robust evidence of one method’s superior- Intraoperative ERCP (with concomitant laparoscopic
ity over another. The local availability of both technical cholecystectomy)
resources and professional expertise could also play a The single-stage laparoendoscopic treatment, known as
pivotal role in deciding which treatment to administer. the “Rendez-vous Technique” (RVT), is used to indicate
simultaneous LC and intraoperative ERCP, facilitated by
Open surgery papilla visualization and cannulation through a guide-wire
From a historical point of view, CBD exploration has the surgeon inserts into the cystic duct. The technique
been performed at the same time as a cholecystectomy was first described almost 20 years ago[52-54], and hypo-
by open choledochotomy with papillotomy and stone thetically, it combines many advantages, such as minimal
extraction, often with a T-tube placement, with an unac- invasiveness and an acceptable learning curve, at the
ceptable morbidity and mortality[11,46]. Therefore, it was price of some organization troubles between endosco-
proposed to abandon this method on a routine basis 20 pists, surgeons and operating room personnel[55-57], but is
years ago[47]. A more recent retrospective series reported yet to be accepted. A robust review by La Greca et al[58]
good results with primary closure of choledochotomy analyzed data from 27 papers, which included almost 800
where endoscopic and minimally invasive facilities are patients and compared the RVT to other approaches.
not available[48]. Currently, open choledochotomy and This research showed an overall bile duct clearance of
papillotomy could still play a role in those cases with 92.3% and few complications (1.6%-6% bleeding from
intraoperative unexpected diagnosis of choledocholi- the sphincterotomy and 1.7%-7% pancreatitis). These ad-
thiasis and cholangitis, with bile duct dilatation or where vantages are related to the use of a guide wire that allows
all other endoscopic, percutaneous and laparoscopic ap- a facilitated cannulation of the papilla without the risk of
proaches failed. Open choledochotomy and papillotomy irritating the pancreatic duct.
could also be used in the case of a pre-existing open The initial drawback of the endoscopic step com-
surgery that limits the application of endoscopic ap- pleted in the supine position of the patient has not been
proaches (i.e., Roux-en-Y intestinal reconstruction after confirmed[59]. Many experiences were reported in the
gastrectomy)[11]. literature[60-63], confirming safety, excellent CBD clearance
percentages, and short learning curves. The adjunct of
Preoperative ERCP (and sub-sequential laparoscopic the intraoperative procedure does not prolong hospital-
cholecystectomy) ization of routine LC[64].
A CBD clearance can be carried out by ERCP with en-
doscopic sphincterotomy (ES) before LC in many cases, Concomitant laparoscopic cholecystectomy and
and it is most likely the most common strategy used in common bile duct exploration
the majority of hospitals worldwide[4]. As previously One possible exciting and rational option to address CCL
reported, due to its intrinsic invasiveness, ERCP should is conducting laparoscopic CBD exploration (LCBDE)
be proposed for those patients with confirmed bile duct during routine LC[65]. In this case, the surgeon is able to
stones only. Furthermore, there is the possibility of some resolve the patient’s disease completely during the same
increased difficulty when performing LC after an endo- session, avoiding the risks of sphincterotomy[26] and with-
scopic procedure[49]. Thus, this two-stage strategy raises out the need to conduct further treatments. Additionally,
the problem of a close sequence of pre-endoscopic the abovementioned preoperative step of diagnosis could
imaging through conventional US, MRC or EUS and a be outdated (an IOC is mandatory before LCBDE).
following LC within a maximum of 72 h that, practically, Some surgeons with sufficient expertise in advanced
leads to some organizational problems in a busy hospital laparoscopy have proposed LCBD as an excellent option
setting. The other drawback of any two-stage procedure for CCL[66,67], but acceptance of such a technique in most
is that the patient undergoes two different uncomfortable hospitals is far off due to its steep learning curve, espe-
anesthesiologic sessions. cially when a T-tube has to be used[68].

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 Bencini L et al . Cholecysto-choledocholithiasis

Table 1 Comparison of the available approaches to concomitant lithiasis of gallbladder and common bile duct

Advantages Disadvantages Risks Availability

Single-step
Open cholecystectomy and bile duct clearance Highly effective Highly invasive Surgical complications, Kehr positioning All hospitals
Fully laparoscopic cholecystectomy and bile duct clearance Very effective Highly less Kehr positioning Few hospitals
invasive
Laparoscopic cholecystectomy and intraoperative Very effective Less invasive Endoscopic complications Few hospitals
endoscopic bile duct clearance
Two-step
Preoperative endoscopic bile duct clearance and sequential Very effective Less invasive Unnecessary ERCP, Endoscopic Most hospitals
laparoscopic cholecystectomy complications
Laparoscopic cholecystectomy and sequential endoscopic Effective Less invasive Endoscopic complications, Further Most hospitals
bile duct clearance procedures

ERCP: Endoscopic retrograde cholangiography.

Moreover, the surgeon’s experience influences the One of the first logical consequences of introduc-
choice of technical procedure, such as the extraction of ing ERCP in almost all hospitals was limited mass open
stones by the transcystic route[69] rather than performing operations, while advanced laparoscopy led to comparing
a choledochotomy or the decision to do primary closure the open procedure and CBD clearance with the total
versus T-tube placement[70]. laparoscopic approach. LCBDE was confirmed to be
None of these differences, however, impacted the superior compared to open surgery in terms of mortality
patients’ final outcomes. One of the most challenging and morbidity (but less effective for common bile duct
maneuvers during LCBDE is the placement of a T-tube clearance) since 2006[77]. Theoretically, LCBDE minimizes
after closing the choledochotomy, but the real advantages, the risks of post-ERCP complications[26-29] and the need
in terms of postoperative morbidity, of such a procedure for further anesthesia, with an excellent success rate of
are not confirmed according to a recent review article stone extraction (more than 90%)[67,77]. However, LCBDE
and meta-analysis[71]. remains limited to centers with advanced laparoscopic
expertise[12].
Shifts between the approaches and other techniques Furthermore, the high availability of ERCP in almost
The spectrum of variability of the different approaches all hospitals limited the mass of such study designs, and
is prone to some percentage of failure. Notwithstanding the acceptance of the superiority of LC over open op-
these limitations, almost each of these techniques can eration avoided further protocols. Indeed, one recent
be used if one does not work, raising the overall success prospective trial comparing LCBDE and open surgery
rates. For example, the RVT could be attempted in the confirmed the superiority of the laparoscopic method in
case of uncompleted preoperative ERCP caused by a terms of efficiency, morbidity and mortality[78].
difficult papillary approach[72]. Alternatively, if the guide- When comparing the two-stage (LC with preopera-
wire insertion through the cystic duct during the RVT is tive or postoperative ERCP) and single-stage (LC with
not possible, a skilled endoscopist is able to complete the LCBDE), no significant differences were found, except
one-stage procedure through a conventional intraopera- for some intrinsic characteristics (fewer therapeutic ses-
tive ERCP[57]. Moreover, a failed preoperative or intraop- sions)[79,80]. Another trial[81] reported having a reduced
erative ERCP could lead to an LCBDE or an open inter- hospital stay when using LCBDE.
vention, while a second-look at a multiple-session ERCP A very recent review and meta-analysis[82] of six RCTs
(often with stenting) is always possible with the help of comparing prospectively preoperative ERCP and RVT
shock-wave technologies or percutaneous trans-hepatic concluded that the latter method resulted in a reduced
treatments[73-75]. incidence of endoscopy-related pancreatitis and a shorter
hospital stay, although stone clearance and overall mor-
COMPARING THE DIFFERENT bidity were almost equivalent. Another meta-analysis[83]
included RVT in the so-called one-stage procedure, merg-
TECHNIQUES ing studies regarding LCBDE and comparing this group
In times of reduced resources, it is of utmost importance to the two-stage procedures (LC preceded or followed by
whether the one-stage management of patients with ERCP). Again, no statistically detectable differences in
CCL is associated with reduced costs compared with a patients’ outcomes were recorded between the two strate-
two-stage procedure[76]. However, the economic pressure gies.
should be balanced with some learning curve to gain Another review[84], conducted only by comparing two-
experience with more recent mini-invasive single-stage stage procedure clearance versus RVT, found a reduced
strategies, with the goal of similar patient outcomes. A incidence of postoperative pancreatitis with the latter
summary of the pros and cons of each different strategy method (2.4% instead of 8.4; OR, 0.33; 95%CI: 0.12-0.91,
is shown in Table 1. P = 0.03). Another group[85] published the results of a

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 Bencini L et al . Cholecysto-choledocholithiasis

Pre-ERC

Preoperative LCC

RVT Open

Diagnosis of
Postoperative Post-ERC Intraoperative Repeated
CCL

Post-ERC Alternative

Intraoperative LCC

RVT

Figure 1 A proposed algorithm for a combined-multimodal approach to cholecysto-choledocholithiasis. CCL: Cholecysto-choledocholithiasis; ERC: Erythro-
poietin-responsive cells; RVT: Rendez-vous Technique; LCC: Laparoscopic cholecystectomy.

comparative study of 200 patients, suggesting the superi- clearance, but data referred to the early endoscopy era.
ority of RVT over preoperative ERCP in terms of hospi- Presently, no single study comparing the whole spec-
tal stay. In contrast, the RCT published by Rábago et al[86] trum of treatments (preoperative, postoperative ERCP,
reported similar percentages of CBD clearance between LCBDE, RVT) has been published, most likely due to
the two approaches. A study by Hong et al[87] compared the unrealistic contemporaneous presence of so many
LCDE and RVT, and no differences were found between professionals and dedicated resources in the same facility.
the two groups regarding duration of surgery, success In our department, for example, there is a great availabil-
rate, complications, retained stones, hospital stay, and ity of very skilled endoscopists (three professionals) who
costs. Another study[88] also reported similar ductal stone are able to manage intraoperative ERCP with challenging
clearance rates, although LCBDE was associated with situations, while MRC needs a long time to be scheduled
shorter hospital costs. due to a very busy imaging service. However, it is very
The most updated and comprehensive review of difficult to schedule several LC within an appropriate
available literature likely was published in 2013 by the Co- time after a preoperative ERCP, which is to be balanced
chrane Group[89]. After a careful and rigorous selection, with oncologic patients. Therefore, our approach to CCL
only 16 RCTs, including a total of 1758 patients, were is usually based on the RVT[57].
taken into consideration. The trials compared most of From a theoretic point of view, the best approach
the options available to treat CCL. Although the authors should be that in which all options are available in the
advised about the high risk of bias, they found no signifi- same facility, modulating each one according to the single
cant difference in the mortality and morbidity between patient. Moreover, in the case of failure, other options
open surgery versus ERCP clearance (1% vs 3%, 20% vs could be proposed to guarantee a successful CCL resolu-
19%, respectively). However, patients who received open tion. A proposed algorithm is shown in Figure 1.
surgery had fewer retained stones (6% vs 16%).
Again, there was no significant difference in the main
outcomes between LCBDE and pre-operative ERCP. CONCLUSION
Similar results were found when comparing trials on The current management of CBD stones associated
LCBDE vs RVT or post-operative ERCP. Interestingly, with gallstones requires an adequate approach due to the
there was a detectable difference in the numbers of re- possibility of perioperative morbidity and mortality with
tained stones between LCBDE and postoperative ERCP severe impact on the quality of life. Many strategies are
(9% vs 25%). Therefore, single-staged LCBDE vs two- available at present, mostly involving LC as a pivotal step
staged pre-operative or post-operative ERCP appeared in the entire process. The extremities of the spectrum of
to lead to comparable results in terms of mortality and treatments are represented by open traditional surgery
morbidity, with a non-significant difference in the per- and full laparoscopic cholecystectomy with CBD clear-
centage of retained stones in the single-stage group (8% ance. However, in the majority of hospitals worldwide,
vs 14%, P = 0.94). The authors concluded that open bile ERCP is the preferred choice used to complete an LC.
duct surgery seems superior to ERCP in achieving CBDS Timing of the ERCP (preoperative, intraoperative or

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 Bencini L et al . Cholecysto-choledocholithiasis

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P- Reviewers: Aly EH, Ciaccio EJ S- Editor: Gou SX

L- Editor: A E- Editor: Zhang DN

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