Bile duct clearance, endoscopic or laparoscopic?

Endoscopic sphincterotomy (ES) has become the gold standard nonoperative modality for the removal of common bile duct (CBD) stones. Morbidity is 2%-10%, and mortality less than 2%. Immediate complications include bleeding, cholangitis, pancreatitis, and duodenal perforation, but many of these can be prevented by using various tools, including an alternating coagulating and cutting diathermy unit, routine biliary stenting, frequent use of guide-wires to avoid precutting, and mechanical lithotripsy. Long-term results have shown that the stone recurrence rate reaches 15%, probably due to a strong recurrent tendency inherent to bilirubinate stones. Choice of the appropriate lithotomy modality is of paramount importance to reduce invasiveness. ES is the choice for recurrent or residual stones and for choledocholithiasis alone. Acalculous gallbladders left in place carry no risk of acute cholecystitis. In patients with cholecystocholedocholithiasis, CBD stones should be removed via the cystic duct or by choledochotomy during laparoscopic cholecystectomy, not to preserve the sphincter of Oddi but to reduce the interventional burden. Safety and safeguards of papillary balloon dilation must still be investigated in a limited number of institutions. Marked progress in lithotomy/lithotripsy procedures has almost obviated the need for laparotomy. Patients with CBD stones benefit from the less invasive and more efficient modalities of transpapillary, percutaneous, and laparoscopic lithotomy.