title: Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful.
abstract: BACKGROUND
  Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy.
  
  
  METHODS
  In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct (CBD) exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography (ERCP) was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube insertion without routine intraoperative cholangiography (IOC).
  
  
  RESULTS
  We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 (87.2%) patients. A total of 186 (12.8%) underwent surgery. Of these, 82 (45.2%) had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 (44.1%) patients and choledochojejunostomy was performed in 20 (10.8%). Retained stones were found only in 4 cases which were treated by ERCP.
  
  
  CONCLUSIONS
  ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions.
authors.affiliation: Department of Surgery and Research Center for Improvment of Surgical Outcomes and Procedures, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran.
authors.forename: Abolfazl
authors.initials: A
authors.lastname: Shojaiefard
authors.forename: Majid
authors.initials: M
authors.lastname: Esmaeilzadeh
authors.forename: Zhamak
authors.initials: Z
authors.lastname: Khorgami
authors.forename: Rasoul
authors.initials: R
authors.lastname: Sotoudehmanesh
authors.forename: Ali
authors.initials: A
authors.lastname: Ghafouri
mesh_terms: D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D042883:Choledocholithiasis; D006801:Humans; D016717:Sphincterotomy, Endoscopic