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Gallstone disease is one of the most common digestive disorders requiring hospitalization and one of the most expensive to treat, with a prevalence of 10-15% in adults in Europe and the USA. Between 10 to 50% of patients with cholelithiasis will present with symptomatic gallstones, and up to 70% of these patients will develop complications, such as pancreatitis or cholangitis.
A subset of patients with gallstones, specifically 15%, will have choledocholithiasis at the same time. And of those, in up to 25% the diagnosis will be made during surgery.
So we may come across two different scenarios that require different management: the presence of cholelithiasis, and the concomitance of cholelithiasis and a symptomatic choledocholithiasis (two different situations in one scenario).
How did we manage this disease in the past? A few years ago, in the pre-laparoscopic era, the only treatment we had was surgical, so an open cholecystectomy and a surgical approach to remove the choledocholithiasis was performed.
After the boom of laparoscopic surgery and endoscopic techniques, it was thought that it could be less aggressive to approach both situations separately: an endoscopic technique, such as ERCP, to remove the common bile duct stones, and a laparoscopic cholecystectomy, in a two stage strategy.
With the development of advanced minimally invasive techniques, choledocholithiasis started to be treated using laparoscopic techniques. And today, we are at a point where we are beginning to compare the two different strategies for treatment: the single-stage laparoscopic approach and the two-stage laparoscopic and endoscopic approach, which has been most performed in recent years.
Like any medical problem, it has a diagnosis phase and a treatment phase, but in this disease the two pieces of the puzzle sometimes fit together and the diagnosis and treatment phases can be joint and done at the same time.
The diagnosis of choledocholithiasis is challenging and requires a high degree of suspicion. The initial evaluation of a patient with suspected choledocholithiasis should include a complete clinical anamnesis and physical exploration, laboratory studies including liver biochemical tests, and a transabdominal ultrasound (US) of the right upper quadrant. These are the usual tests available in the Emergency Room.
In 2010 the American Society of Gastrointestinal Endoscopy (ASGE) published guidelines to assist in the risk stratification of patients being evaluated for choledocholithiasis. These guidelines stratify patients into high-, intermediate- and low-risk categories based on clinical criteria, laboratory tests, and abdominal ultrasound.
This parameters that are used to stratify are classified in three groups:
- Very strong predictors:
- Common bile duct stone observed in transabdominal ultrasound.
- Bilirubin levels > 4 mg/dl
- Presence of clinical ascending cholangitis.
- Strong predictors:
- Dilated common bile duct in ultrasound (>6 mm with gallbladder in situ).
- Bilirubin levels between 1.8 - 4 mg/dl.
- Moderate predictors:
- Abnormal liver biochemical test other that bilirubin.
- Age older that 55 years old.
- Clinical gallstone pancreatitis.
Using these predictors it is possible to classify patients into three categories according to their likelihood of choledocholithiasis:
- High risk is defined as the presence of either very strong predictor or the presence of both strong predictors. It denotes a likelihood of common bile duct stones higher than 50%.
- Intermediate risk is defined as the presence of a different combination of predictors and it denotes a risk of common bile duct stones ranging between 10 - 50%.
- The low risk category is established when there isn’t any predictor and the likelihood of finding common bile duct stones is <10%
The American Society of Gastrointestinal Endoscopy also suggested a management algorithm for patients with symptomatic cholelithiasis, based on whether they have a low, intermediate, or high likelihood of choledocholithiasis. The goal of this algorithm is to minimize the number of unnecessary radiologic and endoscopic procedures performed, and to avoid the complications that they can generate.
As we can see in the algorithm, patients with symptomatic cholelithiasis who are candidates for surgery and have a low likelihood of choledocholithiasis (<10%) should undergo cholecystectomy with no further evaluation required, because the cost and risks of additional preoperative or intraoperative biliary evaluation are not justified by the low likelihood of a common bile duct stone. Patients at high risk of choledocholithiasis (>50%) require a further evaluation of the bile duct, so usually a preoperative ERCP is performed, followed by a laparoscopic cholecystectomy.
By contrast, patients with an intermediate likelihood of presenting with common bile duct stones (10 - 50%) after an initial evaluation benefit from additional biliary imaging to further triage the need for ductal stone clearance. There are several options for evaluation of these patients, and those can be preoperative or intraoperative procedures.
As preoperative imaging modalities, we can choose between:
- Magnetic Resonance Cholangiography (MRC): with an 85% to 92% sensitivity and 93% to 97% specificity, but its sensitivity seems to diminish in the setting of small stones <6mm.
Endoscopic Ultrasonography (EUS): it has a similar sensitivity and specificity, and remains highly sensitive for stones <5mm.
- Endoscopic Retrograde Cholangiopancreatography (ERCP): only used for diagnostic or therapeutic purposes, because the risk of adverse events is higher that with noninvasive biliary imaging studies or endoscopic ultrasonography.
As intraoperative techniques we have Intraoperative Cholangiography (IOC) and Laparoscopic Ultrasound (LUS)
- Intraoperative Cholangiography is the gold standard. It has a sensitivity of 59% to 100% and a specificity of 100% for choledocholithiasis, and it usually requires between 10 to 17 minutes to complete. It also requires additional theatre personnel, disposable cholangiography catheters and an image intensifier. As a significant advantage, it makes it possible to detect biliary leaks, as the iodinated contrast dye is injected through the common bile duct with real-time fluoroscopic interpretation by the surgeon.
- Laparoscopic Ultrasound has a reported sensitivity of 71% to 100% and a specificity of 96% to 100%. It does not require ionising radiation and does not require cannulation of the biliary system. However it is user dependent and has a longer learning curve than does IOC.
Both biliary imaging modalities have similar accuracy in the detection of common bile duct stones, as reported in multiple meta-analyses.
The methods currently available to restore biliary potency in these cases include ERCP before or after laparoscopic cholecystectomy (LC), as a two stage treatment, and laparoscopic common bile duct exploration (LCBDE) during LC, as a single stage treatment. In the single stage approach we can also include intraoperative ERCP during LC, but this technique is seldom used.
Laparoscopic common bile duct exploration consists in inserting a choledoschope and extracting common bile duct stones, and it can be performed in a transcholedochal or transcystic approach, the latter being preferred as it avoids morbidity induced by common bile duct incision and the possible adverse results arising from T-tube placement. This technique, as a single stage approach, in contrast to ERCP + LC , has the advantage of preserving the function of the sphincter of Oddi, and can reduce the overall hospital stay and cost, improving cost effectiveness. However, this highly technical procedure has a longer learning curve, specially when a T-tube, which increases patient discomfort, is used.
Some studies comparing single and two stage treatment have been published, and it has been reported that they present similar clearance results, and comparable morbidity, mortality and requirements for additional procedures.
1.- The presence of choledocholithiasis combined with gallstones has a high prevalence in our society, and generates a high level of sanitary resource consumption for its diagnosis and treatment.
2.- The initial evaluation of suspected choledocholithiasis should include a complete clinical evaluation, serum liver biochemical tests and transabdominal ultrasound of the right upper quadrant. These tests should be used to risk-stratify patients to guide further evaluation and management.
3.- To make a diagnosis of common bile duct stones we can choose between preoperative and intraoperative techniques.
4.- As treatment options, we have ERCP before or after laparoscopic cholecystectomy (LC), as a two stage treatment, and laparoscopic common bile duct exploration (LCBDE) during laparoscopic cholecystectomy, as a single stage treatment. Outcomes after single stage laparoscopic management of common bile duct stones are no different to the outcomes after the two stage approach.
5.- Single stage management demonstrated shorter length of stay and improved cost effectiveness.
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