Surgical Endoscopy and Other Interventional Techniques

https://doi.org/10.1007/s00464-020-07462-2

SAGES CLINICAL SPOTLIGHT REVIEW

Clinical spotlight review for the management of choledocholithiasis

Vimal K. Narula1 · Eleanor C. Fung2 · D. Wayne Overby3 · William Richardson4 · Dimitrios Stefanidis5   on behalf of
the SAGES Guidelines Committee

Received: 26 January 2020 / Accepted: 13 February 2020

© Society of American Gastrointestinal and Endoscopic Surgeons 2020

Abstract
Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis,
and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management
strategies for choledocholithiasis. The following clinical spotlight review is meant to critically review the available evidence
and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques
in the management of choledocholithiasis.

Keywords  Choledocholithiasis · ERCP · Common bile duct exploration · Management · Diagnosis

Choledocholithiasis has a prevalence of approximately Methods

10–15% of patients with symptomatic cholelithiasis [1]. The
clinical presentation of choledocholithiasis can range from
completely asymptomatic to biliary colic and symptoms of
obstructive jaundice, such as pruritus, dark urine and acholic
stools. Although up to a third of patients with common bile
duct (CBD) stones will pass them spontaneously without
intervention, the majority of patients will require endoscopic
and/or surgical intervention [2]. The objective of this docu-
ment was to review best practices in the diagnosis and man-
agement of patients with common bile duct stones.
* Dimitrios Stefanidis
dimstefa@iu.edu
1
Division of General and Gastrointestinal Surgery, The Ohio
State University Wexner Medical Center, Columbus, OH,
USA
2
Department of Surgery, University At Buffalo, Buffalo, NY,
USA
3
Division of Gastrointestinal Surgery, University of North
Carolina At Chapel Hill, Chapel Hill, NC, USA
4
General Surgery, Ochsner Clinic, New Orleans, LA, USA
5
Department of Surgery, Indiana University School
of Medicine, 545 Barnhill Drive, EH 130, Indianapolis,
IN 46202, USA
The working group first determined questions relevant to
the clinical practice of surgeons treating patients with chole-
docholithiasis. It then conducted a PubMed search of all
English language articles in October 2019 published using
the medical subject heading (MeSH) search terms “common
bile duct stones”, “choledocholithiasis”, “ERCP/endoscopic
retrograde cholangiopancreatography”, “common bile duct
exploration”, “diagnosis” and “management”. A total of 725
articles were found and reviewed by the working group; after
exclusion of studies not relevant to our clinical questions 79
full manuscripts were reviewed in detail. Articles pertain-
ing to management strategies for choledocholithiasis and
best clinical scenarios for the application of each strategy
are summarized below under each question. Comparative
evidence was sought where available.
What investigations should be
performed in patients with suspected
choledocholithiasis?
For all patients with suspected choledocholithiasis, obtain-
ing liver transaminases, bilirubin and a transabdominal
ultrasound are recommended as preliminary investigations
to identify patients with high likelihood of common bile
duct stones. Ultrasound findings consistent with choledocho-
lithiasis include visualization of a common bile duct stone

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and a dilated common bile duct greater than 8-mm [3]. The
combination of clinical presentation, laboratory results, and
imaging findings should be considered when deciding on
next steps of management and investigations.
If the diagnosis of choledocholithiasis is still in ques-
tion following these tests, magnetic resonance cholangio-
pancreatography (MRCP) is a non-invasive option, which
has a sensitivity of > 90% and specificity nearing 100% [4].
However, the main disadvantage of MRCP is that common
bile duct stones identified require intervention by another
method to be removed. Other diagnostic modalities to detect
common bile duct stones include endoscopic ultrasound
(EUS) in which an echo endoscope is positioned in the duo-
denal bulb in which the average sensitivity and specificity
is approximately 95 and 97%, respectively [5]. Although
the interpretation of EUS and MRCP are both subject to
bias, meta-analyses have found an observed superiority in
the sensitivity of EUS as compared to MRCP due to better
accuracy of EUS in detection of small stones and as such,
EUS-directed ERCP has been advocated as a cost-effective
method since both EUS and ERCP could be performed in
the same session.
Fig. 1  Management algorithm for patients based on probability of choledocholithiasis
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Surgical Endoscopy
What is the pre‑test probability
of choledocholithiasis in my patient?
Numerous factors have been implicated as prognostic pre-
dictors to help stratify patients into low, intermediate and
high probability of choledocholithiasis. The visualization
of a common bile duct stone on abdominal ultrasound car-
ries approximately a 73% sensitivity and 91% specific-
ity according to a meta-analysis of five studies [6]. Other
strong predictors for choledocholithiasis include clinical
evidence of acute cholangitis, a bilirubin greater than
1.7 mg/dL and a dilated CBD; the presence of two or more
of these factors has a pre-test probability of 50%-94% for
choledocholithiasis (considered high) [7, 8]. Patients
without evidence of jaundice and a normal bile duct on
ultrasound have a low probability of choledocholithiasis
(< 5%) [9]. Patients that fall between these two spectrums
are categorized as having an intermediate probability of
choledocholithiasis. The algorithm presented in Fig. 1 may
be helpful for managing patients with suspected choledo-
cholithiasis dependent on their risk stratification.
Surgical Endoscopy
How should patients with documented
choledocholithiasis be treated?
The management of choledocholithiasis depends on the tim-
ing of common bile duct stone discovery in relation to the
cholecystectomy. The algorithm presented in Fig. 2 dem-
onstrates the recommended approach to choledocholithiasis
dependent on whether it is discovered pre-operatively, intra-
operatively or post-operatively.
What is the pre‑operative management
of choledocholithiasis?
If the diagnosis of choledocholithiasis is confirmed pre-
operatively, there are options of clearance of the CBD
which include endoscopic retrograde cholangiopancrea-
tography (ERCP) prior to cholecystectomy or common bile
duct exploration combined with cholecystectomy which is
described in the next section.
ERCP is highly sensitive and specific for choledocho-
lithiasis with the added benefit of being therapeutic to clear
stones from the biliary tree in an attempt to avoid com-
mon bile duct exploration and prevent distal obstruction.
By directly cannulating the ampulla to access the biliary
tree, a sphincterotomy is often performed with sweeping
and extracting stones from the common bile duct. ERCP
has a success rate of approximately 80–90% for ductal clear-
ance with proper expertise. Reasons for failure include large
Fig. 2  Treatment algorithm for patients with documented choledocholithiasis based on time of diagnosis
or impacted stones, duodenal diverticula, altered gastric or
duodenal anatomy and intrahepatic stones. Risks associ-
ated with ERCP include pancreatitis (1.3–6.7%), infection
(0.6–5%), hemorrhage (0.3–2%), perforation (0.1–1%) and
mortality (up to 1%) [10]. Following biliary clearance with
ERCP, it is generally recommended to proceed with subse-
quent cholecystectomy to prevent the occurrence of recur-
rent episodes of symptomatic cholelithiasis which occurs in
approximately 20% of patients. However, in patients with
advanced comorbidities who are at significantly high risk for
operative intervention, ERCP with sphincterotomy without
any further subsequent intervention can also be considered
definitive therapy, as there has been no statistical difference
in mortality [11, 12].
What is the intraoperative management
of choledocholithiasis?
The diagnosis of choledocholithiasis can be confirmed intra-
operatively during an intraoperative cholangiogram (IOC) or
laparoscopic ultrasound (LUS). The standard IOC method
includes cannulation of the cystic duct or gallbladder with a
fine catheter and direct injection of contrast to visualize the
common bile duct and biliary tree [13]. Laparoscopic IOC
has an approximate sensitivity of 75–100% and a specific-
ity of 76–100% [14, 15]. When choledocholithiasis is con-
firmed intraoperatively, a decision should be made between
common bile duct exploration at the time of cholecystec-
tomy and post-operative ERCP, which is dependent on local
13

availability of surgical and endoscopic expertise. Both IOC
and LUS also allow for evaluation of biliary anatomy which
can aid in determining the optimal approach for biliary clear-
ance. Furthermore, laparoscopic common bile duct explora-
tion is contraindicated in the absence of common bile duct
pathology, in patients with hemodynamic instability, or
when a hostile porta hepatis is encountered intraoperatively
[16].
Laparoscopic common bile duct exploration combined
with cholecystectomy is a feasible and effective option as
a single-stage procedure for the management of choledo-
cholithiasis. A Cochrane review on the topic has shown
that single-stage laparoscopic common bile duct explora-
tion with cholecystectomy and two-stage ERCP followed
by laparoscopic cholecystectomy have similar efficacy rates
in clearing the CBD with no significant difference in patient
morbidity and mortality [17]. Although the single-stage
laparoscopic approach was found to have a longer average
operative time, it was associated with a shorter overall hos-
pital stay and need for fewer procedures, making it a more
cost-effective method for the management of common bile
duct stones in patients undergoing laparoscopic cholecys-
tectomy [18].
Common bile duct exploration was traditionally per-
formed as an open procedure but can be performed laparo-
scopically either via a transcystic approach or transductal
approach. Nevertheless, laparoscopic common bile duct
exploration has not been adopted widely as it is technically
challenging and strongly dependent on surgeon experience
and equipment availability [19]. However, a simulation-
based mastery learning curriculum has been shown to
increase the clinical utilization, skill acquisition and adop-
tion of laparoscopic common bile duct exploration [20].
While the results of this study are promising, the most
important consideration when deciding on the treatment of
choledocholithiasis for an individual patient are expertise in
the procedure, characteristics of the biliary tree, and local
availability of resources.
For the laparoscopic transcystic approach, a transverse
opening is made in the cystic duct prior to its transection.
The common bile duct can then be accessed with a small-
bore catheter for saline flushes, which may be successful in
dislodging stones into the duodenum. 1–2 mg IV glucagon
can also be administered to relax the Sphincter of Oddi to
facilitate passage. If this is not successful, stones can be
extracted with a wire basket or Fogarty balloons under fluor-
oscopic guidance. If the initial ductotomy made for cholan-
giogram is too small, the ductotomy can either be extended
closer to the cystic duct-CBD junction or pneumatic cystic
duct dilatation can be performed under fluoroscopy over
a guidewire. Alternatively, a small caliber choledocho-
scope with a working channel can be passed through the
cystic duct into the common bile duct where a basket stone
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Surgical Endoscopy
extractor can then be used to capture the stones under direct
visualization [16].
If the stones cannot be cleared intraoperatively, laparo-
scopic transcystic biliary stent placement can be performed
under fluoroscopic guidance which can facilitate biliary
drainage and allows for post-operative ERCP to be per-
formed electively and more successfully. Alternatively, a
flexible guidewire can be placed intraoperatively through
a cystic ductotomy into the biliary tree across the ampulla
into the duodenum under fluoroscopy to allow for ERCP via
a “rendez-vous” procedure, in which the duodenoscope can
then be inserted per os to capture the guidewire. A biliary
sphincterotome can then be back-loaded over the guidewire
to allow for direct cannulation of the common bile duct
followed by stone extraction through a single-stage laparo-
scopic-endoscopic approach [21].
Relative contraindications to the transcystic approach
include a small, friable cystic duct, multiple stones in the
common bile duct, stones larger than 1 cm or stones in the
proximal duct [16, 22]. The success rate of stone clearance
via a transcystic approach can reach up to 71% [23].
A transductal approach can be attempted laparoscopically
if the surgeon has the needed expertise and if the common
bile duct is at least 7 mm in diameter to reduce the risk of
post-operative stricture. The anterior surface of the distal
CBD is identified and incised longitudinally to access the
common bile duct. Saline flushes, Fogarty catheters, stone
retrieval baskets and the choledochoscope can then be used
to facilitate clearance of the common bile duct. The chole-
dochotomy can then be closed either primarily using absorb-
able 4–0 or 5–0 sutures or over a T-tube, an antegrade bil-
iary stent or with an external biliary drain depending on the
surgeon’s discretion and the clinical situation depending on
the potential risk of post-operative CBD stricture, increased
pressure within the CBD leading to bile leak or retained
common bile duct stones [16].
If a T-tube is used, the T-tube is left to gravity drainage
post-operatively for 1 week and imaged with T-tube cholan-
giography prior to consideration of removal. The T-tube can
also be given a trial of clamping over a 1 week period prior
to discharge and in the absence of jaundice, fevers and eleva-
tion of liver transaminases, the tube can remain clamped
over 1 week and subsequently be removed at 2 weeks post-
operatively without cholangiography in the absence of
symptoms [24].
Complications of common bile duct exploration include
retained stones (0–5%), bile leak (2.3–26.7%), common bile
duct stricture (0–0.8%) and pancreatitis (0–3%). We suggest
that the reader also reviews the SAGES clinical spotlight
review on laparoscopic common bile duct exploration for
further details [16].
If plans are made intraoperatively for post-operative
ERCP for common bile duct stone clearance, additional
Surgical Endoscopy
measures, such as endoloops or additional laparoscopic
clips on the cystic duct stump and an external drain in the
gallbladder fossa, should be considered to protect against
leakage of the cystic duct stump due to the higher pressures
present in the biliary tree.
What is the post‑operative management
of choledocholithiasis?
If the patient is found to have a retained stone post-opera-
tively, ERCP is the treatment of choice for biliary clearance.
In the case that endoscopic retrieval is unsuccessful, percu-
taneous biliary drainage or less frequently laparoscopic or
open common bile duct exploration may be required.
What are special considerations
in the management of choledocholithiasis?
Patients with choledocholithiasis that present challenges
include those with recurrent CBD stones, large or impacted
stones, altered gastric or duodenal anatomy such as Billroth
II or Roux-en-Y gastric bypass and those presenting with
sepsis secondary to acute cholangitis.
What are the approaches to recurrent common bile
duct stones?
Patients with recurrent stones pose a challenge in the man-
agement of choledocholithiasis. Risk factors for recurrent
stones include multiple common bile duct stones, biliary
dilatation > 13 mm, prior open cholecystectomy, prior gall-
stone lithotripsy, hepatolithiasis or factors leading to biliary
stasis such as periampullary diverticula, papillary stenosis,
biliary stricture or tumor and angulation of the common bile
duct. Treatment of recurrent common bile duct stones typi-
cally includes repeat endoscopic intervention (i.e., ERCP)
but may also be treated surgically in patients who are at
high risk of recurrence. The three main surgical options for
re-establishing biliary drainage include choledochoduoden-
ostomy, hepaticojejunostomy or transduodenal sphinctero-
plasty, which should be further pursued with involvement of
a hepatopancreatobiliary surgeon [25].
What techniques can be employed
to manage large or impacted stones?
Traditionally, patients with CBD stones that were unable to
be extracted endoscopically would have to undergo common
bile duct exploration. However, there are a variety of other
minimally invasive techniques that can be employed prior
to surgical intervention.
What if the biliary system cannot be cannulated
during ERCP or surgery?
If the patient is found to have documented choledocholithi-
asis pre-operatively and a pre-operative ERCP is pursued
without successful cannulation of the biliary tree, a pre-
cut sphincterotomy can be considered, in which a needle-
knife with electrocautery is used to score the region of the
papilla for access. This has been associated, however, with
an increased complication rate of 5–30%, which include
perforation and post-ERCP pancreatitis [18]. Another
well-reported method includes the staged “rendez-vous”
procedure in which the interventional radiologist is able
to place a percutaneous transhepatic guidewire that is fed
retrograde through the papilla into the duodenum that can
then be accessed by the duodenoscope for cannulation [26].
Endoscopic ultrasound-guided biliary drainage via chole-
dochoduodenostomy is also another documented method
of accessing the common bile duct in which the common
bile duct is directly punctured via a transduodenal approach
to both clear and stent the common bile duct but this does
require advanced endoscopic expertise [27].
If the patient is found to have choledocholithiasis intra-
operatively and the biliary tree cannot be successfully can-
nulated for stone extraction, a post-operative ERCP, further
surgical attempts via laparoscopic or open techniques or
percutaneous biliary drainage can be pursued depending
on local expertise and resource availability (Fig. 2). This
is described in more detail in the SAGES clinical spotlight
review on laparoscopic common bile duct exploration [16].
What if I am unable to extract the stone during ERCP
or surgery?
If the patient is undergoing a pre-operative ERCP and
endoscopic attempts with balloon or basket sweeping are
unsuccessful, mechanical lithotripsy by way of capturing
and fragmenting stones with a reinforced basket with a
spiral sheath can be successful in over 80% of cases [28,
29]. There are also through the scope choledochoscopes
(e.g., Spyglass) that are now available that can administer
intracorporeal electrohydraulic or laser lithotripsy. In this
method, energy is delivered directly to a large or impacted
stone under direct visualization with the aid of continuous
irrigation of the CBD. Electrohydraulic lithotripsy involves
shock waves that are delivered in brief pulses directly at the
stone by the probe, which is optimally located approximately
1–2 mm from the stone. Laser lithotripsy involves laser light
of a high-power density, traditionally Holmium:Yttrium-alu-
minum-garnet (YAG) laser, is aimed directly on the surface
of a stone, creating a plasma gaseous collection of ions and
free electrons that then induces oscillation and cavitation
that shatter the stone surface [30].
13

If intraoperative laparoscopic attempts for stone clear-
ance are unsuccessful due to technical reasons, ampullary
edema or distal stricturing, an antegrade ampullary stent can
be inserted laparoscopically under fluoroscopic guidance
either through a transcystic or transcholedochal approach
and allows for post-operative ERCP to be performed (Fig. 3).
This laparoscopically deployed stent sits across the ampulla
in which the internal flap is within the common bile duct and
the external flap is within the duodenum with no externali-
zation of drainage; if the stent is deployed transcystically,
the cystic duct stump can then be ligated with either laparo-
scopic clips or endoloops. Alternatively, a flexible guidewire
can be placed intraoperatively across the ampulla to allow
for concomitant ERCP via a single-stage laparoscopic-endo-
scopic “rendez-vous” procedure as described earlier. The
SAGES clinical spotlight review on laparoscopic common
bile duct exploration can be referenced for further discus-
sion [16].
If these methods continue to be unsuccessful and the
stone is unable to be retrieved, the short-term use of a tem-
porary biliary stent either placed endoscopically, intraopera-
tively or percutaneously via interventional radiology can be
Fig. 3  Example of an antegrade common bile duct stent that can be
inserted laparoscopically under fluoroscopic guidance to allow for
biliary drainage, if biliary clearance cannot be achieved intraopera-
tively. The stent is deployed across the ampulla such that the internal
flap is within the common bile duct and the external flap is within
the duodenum. Image permissions obtained from Cook Medical and
Boston Scientific
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Surgical Endoscopy
used to ensure adequate biliary drainage followed by further
attempts at ERCP or surgery.
What are non‑endoscopic, non‑surgical options
for achieving biliary decompression?
If endoscopic measures are truly unsuccessful, there are a
few options prior to surgical management, which include
percutaneous radiologic treatment, extracorporeal shock
wave lithotripsy and dissolution therapy.
Percutaneous transhepatic biliary drainage (PTBD),
although mainly used in cases of malignancy, can be con-
sidered an accepted alternative method for biliary decom-
pression if the intrahepatic bile ducts are dilated and if other
methods of stone extraction have failed. Either a temporary
external drain, an internal/external biliary drain or an inter-
nal stent can be used to achieve biliary drainage (Fig. 4).
This technique is particularly attractive in the setting of sep-
sis secondary to acute cholangitis in the patient that is hemo-
dynamically unstable and thus, unfit for endoscopic or surgi-
cal intervention. In addition to percutaneous drainage, the
creation of a transhepatic fistula can then allow for the use
Fig. 4  Percutaneous biliary interventions that can be inserted by
interventional radiology. A Example of a percutaneous transhepatic
biliary drain which can either be an external biliary drain in the intra-
hepatic ducts or an internal/external biliary drain that traverses the
ampulla into the duodenum. B Example of an internal biliary stents
that can be placed percutaneously under fluoroscopic guidance. Cred-
its to BSIR and Boston Scientific for permission to use the images of
the internal/external biliary drain and biliary stents
Surgical Endoscopy
of adjuncts via the drain tract such as basket retrieval, elec-
trohydraulic or laser lithotripsy and the “rendez-vous pro-
cedure” following dilation of the tract (techniques described
above) [19]. Although these techniques have high success
rates, there is a significant risk of bleeding via the transhe-
patic tract and it can also cause patient discomfort as well as
dehydration secondary to fluid losses.
Extracorporeal shockwave lithotripsy (ESWL) involves
high-pressure electrohydraulic or electromagnetic energy
that is delivered through a liquid or tissue medium to the
designated target point to fragmenting stones. A naso-bil-
iary drain is inserted by radiology to allow for fluoroscopic
identification and targeting of the common bile duct stones.
The energy setting and number of discharges delivered is
dependent on the device used and patient tolerance as the
main adverse effects include pain, local hematoma forma-
tion, cardiac arrhythmias, biliary obstruction, hemobilia
and hematuria [31]. Furthermore, ESWL has particular
contraindications, such as portal thrombosis and varices of
the umbilical plexus [32]. Despite a ductal clearance success
rate of approximately 60–90%, it is not considered a first-
line treatment for difficult stones and is uncommonly used.
Lastly, administration of oral ursodeoxycholic acid has
been documented to have a potential role in facilitating
stone clearance by reducing the size of common bile duct
stones that are unable to be retrieved endoscopically [33].
The effective dose of ursodeoxycholic acid is between 8
and 12 mg/kg daily for several months. However, its role
in preventing the formation of common bile duct stones is
still unclear.
What techniques can be employed
in patients with altered gastric or duodenal
anatomy?
Patients with choledocholithiasis with altered anatomy,
particularly with Billroth II or Roux-en-Y gastric bypass,
pose significant challenges for biliary clearance due to the
inability to access the biliary tree in the conventional tran-
soral manner. This has been increasing in frequency due to
the popularity of gastric bypass surgery, and is also seen in
patients following gastric resection surgery, Whipple proce-
dure or liver transplantation.
Balloon-assisted ERCP or endoscopic ultrasound-directed
transgastric ERCP (EDGE procedure) can be attempted but
both require advanced endoscopic expertise. In balloon-
assisted ERCP, the enteroscope has a working length of
200 cm and the 12-mm diameter Overtube has a length
of 140 cm. By alternating inflating and deflating the bal-
loons and straightening the scope with the Overtube, the
endoscope is progressed stepwise through the small intes-
tine under fluoroscopic guidance and maneuvered into the
biliopancreatic limb to access the ampulla [34]. Due to the
difficulty in navigation and subsequent cannulation, balloon-
assisted ERCP is not always technically feasible for biliary
duct clearance in these patients. As such, the EDGE pro-
cedure can be an alternative method of accessing the bil-
iary tree in which an anastomosis is created typically with
a lumen-apposing metal stent between the gastric pouch
or jejunum to the excluded stomach under endoscopic
ultrasound visualization which allows a duodenoscope to
be passed to perform a conventional ERCP [35] (Fig. 5).
Although studies show EDGE to be safe and effective, there
are concerns regarding persistent gastrogastric fistula and
weight gain following stent removal in which it is recom-
mended that either an upper endoscopy or upper GI series
be obtained in all patients post-stent removal to determine
the presence of persistent fistula. If present, argon plasma
coagulation and over-the-scope clip placement or revisional
surgery with gastrogastric fistula takedown may be required
for fistula closure [36]. Additional data on the long term
outcomes of this procedure (i.e., how many patients develop
gastrogastric fistulae?) are needed before it can be widely
endorsed. Alternatively, laparoscopic-assisted transgas-
tric ERCP can be used to access the biliary tree in gastric
bypass patients in which the gastric remnant is accessed
Fig. 5  Depiction of endoscopic ultrasound-directed transgastric
ERCP (EDGE) to perform ERCP following Roux-en-Y gastric
bypass. The excluded stomach is located endosonographically from
the gastric pouch or afferent limb and accessed to deploy a lumen-
apposing metal stent into the excluded gastric remnant to allow ante-
grade passage of a duodenoscope through the fistula where conven-
tional ERCP can be performed to access and cannulate the ampulla
and biliary tree. Image permissions obtained from Dr. Prashant Kedia
13

Fig. 6  Depiction of laparoscopic transgastric access of the gas-
tric remnant to perform ERCP following Roux-en-Y gastric bypass.
A 15  mm port is placed into the greater curvature of the bypassed
gastric remnant where the conventional duodenoscope can then be
inserted and advanced to the duodenum to access and cannulate the
ampulla and biliary tree. Image permission obtained from Gastroin-
testinal Endoscopy and Elsevier [41]
laparoscopically and the duodenoscope is inserted through
a gastrotomy made through the gastric remnant [37] (Fig. 6).
If these endoscopic approaches prove unsuccessful, a
common bile duct exploration or PTBD with its associated
percutaneous interventions can then be performed for com-
mon bile duct clearance, which have been described earlier
in this document.
How should patients presenting with sepsis
secondary to cholangitis be managed?
Once the diagnosis of acute cholangitis has been definitively
made in this subset of patients presenting with sepsis, ini-
tial treatment includes IV fluid resuscitation with careful
monitoring of hemodynamic status. Following this, imme-
diate antimicrobial therapy targeted to the biliary tract and
biliary drainage are the key goals of the treatment of acute
cholangitis [38]. The treatment strategy for biliary drainage
should be decided in consideration of the patient’s general
status. In patients who do respond to initial sepsis man-
agement, early internal drainage by transpapillary biliary
drainage during ERCP should be considered first-line as it
not only achieves biliary drainage but also allows for stone
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Surgical Endoscopy
removal. If the stones cannot be extracted concurrently with
biliary drainage in these critically ill patients, two-session
treatment can be pursued with endoscopic biliary stenting
performed as initial treatment followed by endoscopic stone
removal after improvement of cholangitis [39]. However, in
the event of failure of endoscopic techniques or in patients
with rapid deterioration and sepsis-induced organ damage,
percutaneous transhepatic biliary drainage should be con-
sidered as described earlier in this review. Surgical drain-
age and management is generally rare and not advocated in
these critically ill patients due to the increased morbidity and
mortality compared to endoscopic treatment in this patient
population [40].
Conclusion
Choledocholithiasis is a commonly encountered diagnosis
for general surgeons.
The subtleties in the management of common bile duct
stones relate to the decision making on the probability of
choledocholithiasis based on clinical presentation and inves-
tigations, the timing of presentation in relation to laparo-
scopic cholecystectomy in addition to the availability of
technology and expertise of the surgeons, endoscopists and
interventional radiologists. Regardless, the surgeon must be
familiar with all possible options at their disposal for manag-
ing the patient presenting with choledocholithiasis which are
highlighted in this document.
Disclosures
Eleanor C. Fung is a consultant for Boston Scientific and
has received travel reimbursements from Cook Medical and
Fujifilm. Vimal K. Narula, D. Wayne Overby, William Rich-
ardson, and Dimitrios Stefanidis have no conflicts of interest
or financial ties to disclose.
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