Abstract

Background: Choledocholithiasis occurs in approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they may remain asymptomatic or generate symptoms like biliary colic, jaundice, cholangitis, pancreatitis. Confirmatory diagnosis is made with imaging which includes ultrasonogram, Magnetic resonance cholangiopancreatography (MRCP) and Endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require surgical CBD exploration. Knowledge of these treatment strategies will optimize outcomes. The aim of this study is to explore and assess various treatment strategies employed in cases of choledocholithiasis in our setup and to determine their outcome.

Materials & Methods: A retrospective database containing 106 cases with choledocholithiasis from June 2016 to March 2018 were evaluated. All the patients underwent ultrasonography (USG), MRCP and had their liver function tests estimated. ERCP was done when necessary. Other causes of obstructive jaundice like benign or malignant strictures, periampullary carcinomas, post cholecystectomy strictures were excluded from the study.

Results: Of the 106 patients in this study, 57.5% were men and 42.5% were women. The mean age was 48.7 years (range 40-60 years). A total of 30 (28.3%) patients underwent ERCP guided stenting along with stone withdrawal and sphincteroplasty, followed by Laparoscopic cholecystectomy. 45 (42.45%) patients had failed stone withdrawal for whom biliary stenting was done. These patients underwent open cholecystectomy and CBD exploration with primary repair. 28 (26.41%) cases with stone size more than 15 mm directly underwent open cholecystectomy and CBD exploration with T-tube drainage. Average size of the stone for which extraction via ERCP was done is 11.8 mm. One case of recurrent choledocholithiasis was managed with Roux-en-Y hepaticojejunostomy. Two cases of choledocholithiasis with markedly dilated CBD were managed with choledochoduodenostomy.

Conclusion: The management of choledocholithiasis has reached a point in its evolution where more options are available than some institutions can support. The data currently available support a wide range of satisfactory treatment algorithms. Treatment may be endoscopic, percutaneous, open, or laparoscopic. Given the multiple alternatives available, sometimes it is difficult to decide on the right one for a particular patient. Frequently, the best path is the one the surgeon is most adept at or the one that local expertise can accomplish most safely. A two-staged procedure consisting of ERCP, followed by laparoscopic cholecystectomy, should be the first line of treatment for common bile duct (CBD) stones. In cases where ERCP fails or stone size is larger, open surgical procedures still remain a relevant and a definitive option in resource-constrained setups.

Keywords: Choledocholithiasis– endoscopic retrograde cholangiopancreatography– cholelithiasis– surgery.