Common bile duct exploration
- W Scott Melvin, MD
W Scott Melvin, MD
- Professor of Surgery
- The University Hospital for Albert Einstein College of Medicine
- Peter Muscarella, MD
Peter Muscarella, MD
- Director of Pancreatic Surgery
- Montefiore Medical Center
- Albert Einstein College of Medicine
Common bile duct (CBD) stones are identified in 10 to 15 percent of patients undergoing surgery for symptomatic cholelithiasis . CBD stones require extraction for management of symptoms and to prevent complications such as acute suppurative cholangitis, obstructive jaundice, hepatic abscess, and acute pancreatitis.
Traditionally, CBD stones were diagnosed with intraoperative cholangiography and treated with open CBD exploration. Advances in preoperative imaging technology such as magnetic resonance cholangiopancreatography (MRCP) (image 1 and image 2) and endoscopic ultrasound (image 3), as well as the development of endoscopic retrograde cholangiopancreatography (ERCP), and minimally invasive surgical techniques have allowed for less invasive and more accurate methods of identifying and treating CBD stones.
This topic will review laparoscopic and open CBD exploration. The diagnosis and the endoscopic treatment of choledocholithiasis are discussed elsewhere. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management" and "Endoscopic management of bile duct stones: Standard techniques and mechanical lithotripsy".)
IDENTIFICATION OF CBD STONES
The potential existence of common bile duct stones should be considered for all patients with symptomatic cholelithiasis. These patients should be evaluated individually to minimize the risk of retained stones. Clinical findings suggestive of CBD stones include right upper quadrant pain with radiation to the back, jaundice, cholangitis, and pancreatitis.
Transabdominal right upper quadrant ultrasonography and liver function tests are the initial studies of choice for patients with cholelithiasis. Elevated liver function tests, age >55 years, and CBD dilation are generally considered to be predictors of CBD stones and suggest further evaluation. A multivariate analysis identified alkaline phosphatase, total bilirubin, amylase, and CBD dilatation at ultrasonography as independent predictive factors of CBD stones . These results, along with the clinical presentation, can be used to stratify the risk of CBD stones prior to performing cholecystectomy. The probability of having CBD stones can then be used to plan appropriate intervention (algorithm 1). The preoperative evaluation of suspected choledocholithiasis is discussed in detail elsewhere. (See "Choledocholithiasis: Clinical manifestations, diagnosis, and management".)
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- IDENTIFICATION OF CBD STONES
- INDICATIONS FOR CBD EXPLORATION
- PREOPERATIVE PREPARATION
- Prophylactic antibiotics
- INTRAOPERATIVE CHOLANGIOGRAPHY
- SURGICAL APPROACHES FOR CBD EXPLORATION
- Laparoscopic transcystic exploration
- Laparoscopic choledochotomy
- Open CBD exploration
- PERSISTENT STONES
- POSTOPERATIVE MANAGEMENT
- SUMMARY AND RECOMMENDATIONS