Management of preoperatively suspected choledocholithiasis: a decision analysis.
BACKGROUND
The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.


METHODS
A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.


RESULTS
One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality.


CONCLUSIONS
LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.
Kharbutli
Bilal
B
Division of General Surgery, K-8, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI 48202, USA.
Velanovich
Vic
V
D002758:Cholangiography / Q000379:methods*; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D015331:Cohort Studies; D003661:Decision Support Techniques; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007902:Length of Stay; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011300:Preoperative Care / Q000379:methods; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015996:Survival Rate; D016896:Treatment Outcome