Over the last 20-30 years, the treatment of concurrent gall bladder and CBD stones has progressed dramatically. If any common bile duct stones were discovered during cholangiography in the age of open surgery, open CBD exploration (choledocholithotomy) was undertaken. Following the introduction of ERCP, open CBD exploration was reserved for patients with failed ERCP. Earlier diagnosis of CBD stones used to be made by clinical symptoms, preoperative ultrasound, LFT’s and preoperative intravenous cholangiography. Nowadays intravenous cholangiography has been replaced by magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) and ERCP. There remains a conflict of opinion in approach to treatment of cholelithiasis with choledocholithiasis. Available options range from open surgery, endoscopic and laparoscopic exploration.

With the advent of various modern technologies, open surgical procedures, such as CBD exploration or biliary-enteric bypasses, are now usually considered where ERCP fails to retrieve stones or where facilities of advanced laparoscopic surgery are not available. A relative indication for open exploration is large or multiple stones or the need to perform a trans duodenal sphincteroplasty. Laparoscopic common bile duct exploration: Because over 80% of cholecystectomies are done laparoscopically, simultaneous laparoscopic common bile duct exploration can be done. The advantage is that the gallbladder and CBD stones are taken care of simultaneously in a minimally invasive manner. Successful laparoscopic management of CBD stones depends on several factors including surgical expertise, adequate equipment, the biliary anatomy and the number and size of CBD stones. The most direct method of dealing with choledocholithiasis preoperatively is by endoscopic retrograde cholangiopancreatography (ERCP). It was introduced in 1968 by Drs. McCune, Shorb and Moscovitz [1]. Decompression of the ductal system can be achieved by means of endoscopic removal of stones with or without sphincterotomy. This procedure has a reported success rate of 70% to 90%. Because the published morbidity rates for ERCP and laparoscopic common bile duct exploration are roughly equivalent, ERCP plus or minus sphincterotomy followed by laparoscopic cholecystectomy is a good technique.               

Generally, in well-equipped centers of the world, ERCP followed by laparoscopic cholecystectomy is recommended as a safe and cost-effective procedure. However, various centers advocate laparoscopic cholecystectomy with common bile duct (CBD) exploration or a Rendezvous technique where endoscopy and laparoscopy are performed simultaneously. They both have a similar efficacy profile with the added benefit of saving time [2]. The objective of this study is to explore and assess treatment strategies employed in cases of cholelithiasis with choledocholithiasis and to determine their outcome.

This cross-sectional study was carried out in the Department of General Medicine, Shadan Institute of Medical Sciences, Teaching Hospital and Research Centre, Hyderabad on patients admitted with diagnosis of Cholelithiasis with choledocholithiasis from January 2020 to June 2020. This study comprised of 120 patients of cholelithiasis and choledocholithiasis diagnosed by ultrasound or MRCP. Consent of all patients was taken. Detailed history was taken, thorough clinical examination was done and required investigations were done.

Inclusion criteria

All diagnosed cases of cholelithiasis with choledocholithiasis.

Exclusion Criteria

• Patients below 20yrs and above 70yrs of age

• Patients with empyema gall bladder and cholangitis

• Patients in whom prior cholecystectomy has been done

• Pregnant patients, immunocompromised patients and patients with suspicion of carcinoma

• Patients with uncontrolled DM/HTN/thyroid disorders

Method

All the patients who were diagnosed to have gallstones with choledocholithiasis were included in the study. Patients had undergone biochemical and radiological investigations CHG, RBS, RFT, Electrolytes, LFT, Serum Amylase, Serum Lipase, CXR, USG Abdomen and MRCP. Therapeutic decision making was based on expertise availability, number and size of CBD stones, impacted stones and presence of stricture at the lower end of CBD. Laparoscopic cholecystectomy with laparoscopic exploration of CBD was done in some cases depending on availability of expertise. In all cases, operative findings were noted, post-operative morbidity and mortality were noted.

Out of one hundred eight patients, patients were posted for:

• ERCP followed by Cholecystectomy

• Open cholecystectomy with choledocholithotomy with Primary closure of CBD or T-tube drainage:

  • Open cholecystectomy with choledocholithotomy with Primary closure of CBD

  • Open cholecystectomy with choledocholithotomy with T- tube drainage

• Open cholecystectomy with choledocholithotomy with Choledochoduodenostomy

• Laparoscopic Common Bile Duct Exploration with Primary closure or T- tube drainage

Statistical Analysis

Data was entered in Microsoft excel spreadsheet, cleaned for errors and was analyzed using Stata Software version 15. Descriptive statistics were used to summarize the demographic data. Frequencies, percentages and their 95% confidence intervals were used to describe categorical variables.

Table 1 shows that out of 120 patients of Cholelithiasis with choledocholithiasis, seventy-eight patients (65.0%) underwent ERCP. Out of these seventy-eight patients, 67 patients (85.89%) were cleared of CBD stones and underwent cholecystectomy. Out of Sixty-seven patients, laparoscopic cholecystectomy was performed in 60 patients (89.55%) and 7 patients (10.45%) were subjected to open cholecystectomy. Thirteen laparoscopic cholecystectomies were done within 72 hours of ERCP and forty-seven were done after 6 weeks. Out of sixty patients posted for laparoscopic cholecystectomy, five were converted to open cholecystectomy (8.33%).

Table 1: Different modalities of management of cholelithiasis with choledocholithiasis

Out of one hundred twenty patients, 78 patients (65.0%) were subjected to ERCP clearance for the CBD stones. Out of these seventy (89.7%) patients were cleared of CBD stones while 8 patients (10.3%) had failed ERCP. These patients with failed ERCP were then subjected to open procedure (CBD exploration). Nine patients were subjected to Laparoscopic clearance of CBD. Forty-four patients were dealt with open procedure (including patients with failed ERCP) and they had successful CBD clearance (Table 2, Figure 1).

Table 2: Number of patients in which ERCP was done

Figure 1: Results of ERCP

Choledocholithiasis has an incidence of 10-15% in patients with cholelithiasis. There are several options for management of cholelithiasis with choledocholithiasis. (Laparoscopic CBD Exploration) as a better option. But this policy is not widely accepted, probably due to its steep learning curve and equivocal results with other alternatives [3]. In this study 78 patients were subjected to ERCP. Out of seventy-eight, 70 patients (89.7%) had successful ERCP clearance. In study done by Salem in Group B (ERCP f/b LC), ERCP was successful for 21 of 25 patients (84.0%) [4]. A study done by Wei et al. [5] showed the ductal stone clearance was successful in 51 out of 57 patients (89%), which is in comparison is nearly equal to our study. In Twelve patients (16.67%) CBD couldn’t be cleared (failed ERCP). In study done by Salem et al. [4], CBD stones could not be cleared by ERCP in 4 patients (16%) which is similar to our study. From 52 patients in whom laparoscopic cholecystectomy was done, 44 was successful (84.62%) and 8 were converted to open cholecystectomy (15.38%). The causes of conversion were bleeding (seven cases) and dense adhesions (one case), Also LC was completed for 19 of 21 patients (85.7%) and converted to open cholecystectomy in two cases (14.3%).

Nandesh et al. [6] did a study in which laparoscopic to open conversion rate was 10%. In our study, in 5 patients (4.2%) open cholecystectomy with choledocholithotomy with primary closure was done. In four patients (3.3%) open cholecystectomy with choledocholithotomy with T- tube drainage was done and in thirty-six (43.2%) patients open cholecystectomy with choledocholithotomy with Choledochoduodenostomy was done. All patients in this study group were cleared of their CBD stones. Ambreen et al. [7] observed that out of total 35 patients in their study group, sixteen underwent primary closure and in nineteen patients closure over T-tube was done. All had successful CBD clearance. Sharma et al. [8] did a study in 2017 in 14 patients in whom open cholecystectomy with choledocholithotomy with T-tube drainage resulted in complete duct clearance in 93% of patients. One patient having a residual CBD stone discovered on postoperative T-tube cholangiography, which was retrieved by endoscopic management before removal of T-tube.

Laparoscopic Common Bile Duct Exploration was done in nine (10.8%) patients during the study period, 5 (55%) with primary closure of CBD and 4 (45%) with closure over T- tube. Nine patients who were subjected to laparoscopic common bile duct exploration stone were cleared in 7 patients (77.7%). This is in comparison to a study done by Bansal et al. [9] in year 2013 in which the success rates of laparoscopic CBD exploration and clearance of CBD was 91.7%. In our study, success rate in clearance of CBD stones in ERCP, Open CBD exploration (primary closure, T-tube drainage, choledochoduodenostomy) and Laparoscopic CBD exploration was 89.7 %, 100% and 77.7% respectively.

MRCP is a useful investigation for the diagnosis and assessment of any associated problems and provides a roadmap for surgery. Laparoscopic completion cholecystectomy is feasible, but is technically difficult and has a high conversion rate.

1. Wanis, K.N. “Endoscopic retrograde cholangiopancreatography: A review of technique and clinical indications.” Journal of Gastrointestinal and Digestive System, vol. 4, no. 4, 2014.

2. Ghazanfor, R. et al. “Choledocholithiasis: treatment options in a tertiary care setup in Pakistan.” Cureus, 2017.

3. Herrero, A. et al. “Does the surgeon’s experience influence the outcome of laparoscopic treatment of common bile duct stone?” Surgical Endoscopy, vol. 27, no. 1, 2013, pp. 176-180.

4. Salem, M. et al. “Comparative study between laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis.” International Surgery Journal, vol. 6, no. 7, 2019, p. 2250.

5. Wei, Q. “Management of choledocholithiasis: comparison between laparoscopic common bile duct exploration and intraoperative endoscopic sphincterotomy.” World Journal of Gastroenterology, vol. 9, no. 12, 2003, p. 2856.

6. Nandesh, M. et al. “Ideal timing for laparoscopic cholecystectomy post ERCP in patients with choledocholithiasis and cholelithiasis.” Indian Journal of Applied Research, vol. 5, no. 10, October 2015.

7. Ambreen, M. et al. “Primary closure versus T-tube drainage after open choledochotomy.” Asian Journal of Surgery, vol. 32, no. 1, 2009, pp. 21-25.

8. Sharma, R. et al. “Is it time to write obituary for open choledocholithotomy in the present era of endoscopic management? Outcome of surgery for failed endoscopic extraction: a retrospective study.” International Surgery Journal, vol. 4, no. 4, 2017, p. 1350.

9. Bansal, V.K. et al. “Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial.” Surgical Endoscopy, vol. 28, no. 3, 2013, pp. 875-885.