Introduction

Decision-making processes are shorter and easier when there are few options to choose. In the past, when a surgeon diagnosed bile duct lithiasis (before, during or after surgery), he/she performed a cholecystectomy, intraoperative cholangiography (IOC), choledocotomy, stone removal, placement of a Kehr’s “T” tube and after the control cholangiography the procedure ended. Some cases might require primary closure of the common bile duct or duodenotomy (with removal of a retained stone and sphincteroplasty), or bilio-digestive bypass. Later, and inevitably, more diagnostic and therapeutic tools appeared, as laparoscopic surgery, magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), turning decision-making processes more complex.

Management guidelines

A systematic review of 14 international guidelines for the management of gallstones concluded that the overall quality of the guidelines was low and that most recommendations were based on low level of evidence and are subject of controversy¹.

The Southwestern Surgical Congress Multi- Center Trial emphasized the variability within the institutions for the management of choledocholithiasis². Every surgeon would like that the list of options for the management of a given problem (as choledocholithiasis) was supported by conclusive evidence provided by studies with strong evidence and including all the variables (age, symptoms, comorbidities, laboratory tests, findings of imaging tests, bile duct diameter and size, number and location of stones, type of procedure, material, expertise, and outcome, among many others). That study does not and will probably never exist. We will have to feel satisfied with the many studies that have focused on the matter with a non-comprehensive approach, and like an unfinished puzzle, each surgeon will use his/her common sense to identify the missing pieces in each case. For these reasons, I do not believe that there may be an algorithm for the management of choledocholithiasis which considers all these variables.

Let us start with the puzzle: I would like to raise three initial baseline scenarios before starting the search for answers. This information is not necessarily present in all the publications, which may bias our conclusions.

▪▪1) Does bile duct lithiasis occur in a patient with gallbladder or without it? When a patient has choledocholithiasis and cholelithiasis, the decision to perform surgery (cholecystectomy) is not discussed. The different options focus on the management of choledocholithiasis, which is the purpose of this review. In patients with bile duct lithiasis after cholecystectomy, ERCP is the management of choice³.

▪▪2) Was the diagnosis of choledocholithiasis preoperative, intraoperative or postoperative?

Preoperative and postoperative diagnoses are based on similar findings: clinical data, laboratory tests, imaging tests (ultrasound, MRCP, EUS, ERCP, or cholangioscopy, among others), Intraoperative diagnosis is made by IOC, ultrasound or choledochoscopy

▪▪3) Does the diagnosis of bile duct lithiasis include details of the stones (size, number, location, or impacted stones) and ducts (diameter, anatomy).

If the diagnosis of choledocholithiasis is made BEFORE laparoscopic cholecystectomy (LC), which are the options?

▪▪1) Endoscopic removal of common bile duct stones (CBDS) and then LC (two-stage procedure). Preoperative ERCP is the most common option^4,5. The disadvantages of this strategy are related with the complications of ERCP (pancreatitis, bleeding, duodenal perforation and cholangitis, among others) and the greater cost. Yet, one of the advantages of this strategy is that once the bile duct stones are removed, cholecystectomy is done faster. Absence of cholechotomy and its eventual complications. It does not require the logistics or expertise of surgical exploration of the bile duct.

▪▪2) Laparoscopic cholecystectomy plus laparoscopic common bile duct exploration (single-stage procedure). This approach is being recommended more commonly in many papers^6-8. There are two different approaches to perform laparoscopic common bile duct exploration: transcystic and through a choledochotomy, which can be managed with primary closure alone or with a T-tube or by placing a stent across the papilla⁹. Intraoperative ERCP is another possibililty^10,11. This means that the single-stage approach has multiple variables that need to be individually analyzed and compared to reach a conclusion. For Gupta⁵, choice depends on the number of stones, size of stone and diameter of the cystic duct and common bile duct. He also recognizes there is still lack of agreement for the management of choledocholithiasis. In fact, the decision depends on several factors.

▪▪3) Laparoscopic cholecystectomy and postoperative ERCP. This approach should be restricted to very particular situations, as need for short operative time, presence of intraoperative events or lack of adequate logistics. This option is most often used when the diagnosis was not made preoperatively.

▪▪4) Open cholecystectomy and common bile duct exploration. This approach should be limited to certain cases of impacted stones, suspected associated neoplasm, anatomic abnormalities, need for a complementary complex procedure and dense adhesions¹².

Some studies have demonstrated that the single-stage approach is better than the two-stage procedure^6-8. Yet, other studies have reported similar results in terms of morbidity, mortality and residual stones^5,7 while others concluded that a two-stage procedure is better¹³. The British updated guideline on the management of common bile duct stones³ concluded that there are no differences in efficacy, morbidity and mortality between laparoscopic exploration and perioperative ERCP based on high quality studies with strong level of evidence. The 2019 ASGE guideline¹⁴ recommended perioperative ERCP or laparoscopic treatment be performed depending on local surgical and endoscopic expertise.

Pan¹⁵ published a meta-analysis comparing single-stage laparoscopic common bile duct exploration (LCBDE) and LC with preoperative ERCP and then LC and concluded that the single-stage procedure presented better outcomes for all the parameters, recommending this approach. Yet, some results are questionable, as the longer operative time which was significantly greater in the two-stage approach, when one might suppose that laparoscopic exploration of the bile duct significantly could prolong the surgical procedure. In addition, he reported that the percentage of conversions was significantly lower in the single-stage approach despite this strategy was more complex.

In a meta-analysis, Ricci et al.¹⁰ compared four strategies: 1) preoperative ERCP plus LC; 2) LC plus LCDBE; 3) LC plus intraoperative ERCP; and, 4), LC plus postoperative ERCP, and concluded that the best results in terms of success and morbidity were achieved with intraoperative ERCP. The other three procedures had advantages and disadvantages as biliary leak and pancreatitis. Endoscopic RCP after LC is the approach less evaluated.

A meta-analysis by Tan et al.¹¹ comparing preoperative ERCP with ERCP during LC reported fewer complications, lower rate of pancreatitis and shorter length of hospital stay with similar outcome in common bile duct clearance.

Intraoperative ERCP requires two teams working in harmony. Furthermore, a successful removal of stones in the supine position has its own characteristics. When two teams are working together, overlapping may occur in terms of coordination, leadership, management of indications and responsibility of complications.

It is worth mentioning that the definition of one method being better than another is not standardized because there are many variables involved; one approach can be considered better or worse in terms of mortality or morbidity. Moreover, complications are not comparable as post-ERCP pancreatitis and biliary fistula after bile duct repair. The definition of success in removing all the stones is neither standardized, as it can be evaluated by postoperative cholangiography, choledochoscopy, imaging tests, clinical outcome or recurrence, or by the presence of residual lithiasis or stenosis, length of hospital stay, costs, return to work, or how often it is used by surgeons or institutions.

In fact, the issue is controversial and will probably remain so due to the difficulty of comparing two different procedures (surgery or endoscopy) with many variables involved and different quality control.

If the diagnosis of choledocholithiasis is made DURING LC, which are the options?

There are three options:

▪▪1) Laparoscopic surgery to resolve cholecysto-choledocolithiasis through a single-stage approach,

▪▪2) Conversion to open surgery to resolve cholecysto-choledocolithiasis through a single-stage approach.

▪▪3) Complete LC, IOC and postoperative ERCP (two-stage approach).

The first two options have been already described. The most important dilemma lies in the third option: complete LC and postoperative ERCP for stone removal or proceeding with any of the first two options? Any of these decisions should be thoroughly evaluated.

Firstly, this finding is a surprise for the surgeon, the patient and his/her family. Even if before surgery the surgeon gave a thorough explanation of the different treatment options in case of unexpected findings, the advantages and disadvantages of this finding are many and hard to understand. Moreover, if the explanation is given within a hypothetical framework and without the information of the actual scenario, as the number of stones, size, location, actual diameter of the bile duct, possibility of exploring through transcystic approach or choledocotomy or need for drainage, among others.

Furthermore, a surgeon’s attitude towards an unexpected finding is different when dealing with a procedure with low or high morbidity and mortality or when there is only one treatment or different treatment options. It is also different when the procedure is supported by consensus and evidence or is controversial or at least optional or matter of debate.

One possibility is to pause the operation so that the surgeon can explain the findings and the different options already mentioned to the patient’s family that will probably be overwhelmed by the scenarios and leave the decision on the surgeon. Obviously, the patient cannot participate, and there is no time for the family to request a second opinion to ease the burden of the decision.

Transcystic extraction is an option to resolve the problem with low morbidity. Intraoperative ERCP is another possibility. A transcystic drain could be placed to facilitate subsequent cannulation of the papilla.

Some more complex procedures can produce greater morbidity. In case of complications (as biliary leak after bile duct repair) the patient could argue why the stone was not left to be removed via ERCP in the postoperative period.

On the other hand, if the stone is found in the bile duct and the LC is completed, the ERCP is postponed for the postoperative period and any complication occurs (post-ERCP pancreatitis, biliary peritonitis due to clip displacement from cystic duct stump), the patient could question the attitude of not exploring the bile duct during surgery. In case ERCP fails, the patient may have to undergo a new operation or percutaneous radiological stone extraction^3,16. Some recommendations might seem obvious:

Do not explore bile duct by laparoscopy or decide post-operative ERCP if one lacks proper training and logistics.

Bile duct diameter: avoid choledochotomy in a thin bile duct.

Number of stones: multiple stones in the common bile duct should not be managed by endoscopy. Stones size: large stones are usually better managed by surgery.

Analyze if the anatomy of the cystic duct is suitable or not to be approached. Some other considerations such as age, comorbidities or cholangitis may tip the balance of decisions one way or the other.

Thus, efforts should be made to reach the diagnosis before surgery.

It is completely different to make the diagnosis before surgery than during the surgery. If the surgeon knows that the patient has common bile duct lithiasis before performing a LC, the menu of options increases. The specific characteristics of the stones, the anatomy of the bile duct (including the cystic duct) and other anatomic variants can be specified. Logistics may be better planned, and the patient may be involved in the decision-making process (the patient does not usually participate in this process in all the papers published). The patient can sign a specific informed consent form. There can be better coordination with insurance companies, among many other advantages, All these options are not possible if the diagnosis is intraoperative which should be the exception.

However, a publication¹⁶ reported that the diagnosis was made by IOC and the stones were treated after surgery. Interestingly, the presence of stones was only confirmed in half of the patients (by EUS). Most confirmed stones (25/26 patients) were successfully extracted by ERCP except in one patient who needed a percutaneous approach because of duodenal diverticulum.

The literature is consistent in considering that common bile duct stones are detected with an incidence of 4-20%¹¹. Yet, despite the publications do not specify if the diagnosis was made before or doing surgery, the context suggests that the diagnosis was preoperative.

The 2010 ASGE guideline¹⁷ suggests LC without IOC for patients with low likelihood of choledocholithiasis. The updated 2019 guideline¹⁴ suggests that patients with high probability of choledocholithiasis (bilirubin >4 mg/dL, cholangitis, dilated duct or a stone on ultrasound) or at intermediate risk for choledocholithiasis (abnormal liver tests, age > 55 years, or dilated common bile duct) undergo EUS, MRCP, IOC or intraoperative ultrasound for further evaluation. For low-risk patients, the recommendation is LC with or without IOC.

If ERCP fails due to size and number of stones, impacted stones, papilla within a duodenal diverticulum, Mirizzi syndrome, stenosis, anatomic anomalies, the options are to repeat the procedure with the help of a guidewire introduced percutaneously³, or perform laparoscopic or conventional common bile duct exploration or percutaneous radiological stone extraction^3,16. Gad concluded that in case of failed ERCP, large difficult common bile duct stones can be managed either by open surgery or laparoscopy with acceptable comparable outcomes¹². Recently, an EUS guided approach of the bile duct through the stomach or duodenum has been developed¹⁸.

Some special situations

There is no clear position in case of choledocholithiasis without cholelithiasis, but endoscopic stone extraction without cholecystectomy is an option³. For uncommon cases as this one, decisions should be made on an individualized basis.

In patients with Billroth II anatomy, the recommendations are to use of a forward viewing endoscope or limited sphincterotomy supplemented by endoscopic papillary balloon dilation³. Patients with Roux-en-Y gastric bypass: ERCP with enteroscope. Another option is to approach the gastric remnant percutaneously, advance the duodenoscope through a gastrostomy and perform the ERCP¹⁹. Laparoscopy-assisted ERCP is also feasible²⁰.

Conclusions

▪▪The optimal management of the common bile duct is still controversial.

▪▪Deciding on endoscopic, laparoscopic or conventional management for common bile duct lithiasis requires adequate logistics, institution, training and clinical judgment.

▪▪Due to the great diversity of elements involved in the decision-making process, each case must be analyzed individually.

▪▪The preoperative diagnosis allows better management for decision-making.

▪▪Conventional surgery is still in valid option in individualized cases.