Chapter 9: Evaluation of different modalities of management of CBD stones

During the management of a case of CDB stones the surgeon is faced with many options. A wide array of techniques and tools are at a surgeon's disposal. The initial step is to determine the important factors regarding which modality of treatment will best serve the patient. Factors such as diameter and anatomy of the cystic and CBD, number and size of CBD stones, clinical status of the patient, and most importantly, technical skill of the surgeon should all be considered (Chari 2008).

Open surgery versus laparoscopic surgery

Although traditional open surgery is an effective and safe option for the management of cholelithiasis with choledocholithiasis, nowadays with advancing technology, stone extraction can be performed through LCBDE with high efficiency, minimal morbidity, and lower mortality (Grubnik et al., 2012).

ERCP versus laparoscopic surgery

As for the ERCP versus laparoscopic surgery comparisons, LCBDE is proving to be as safe and efficient as ERCP in achieving CBD clearance. There was no clear benefit in terms of primary treatment failure, morbidity, or mortality. Laparoscopic choledochotomy, as opposed to TC-LCBDE, is at least as efficient as ERCP in achieving clearance (Martin et al., 2006).

Another meta-analysis compairing surgical approach (both open and laparscopic) to ERCP concluded that both approaches have similar outcomes, and treatment should be determined by local resources and expertise (Clayton et al., 2006).

The National Institutes of Health state-of-the-science statement on ERCP for diagnosis and therapy indicates that LCBDE and postoperative ERCP are comparable in safety and clearing stones from the CBD duct. However, the consensus panel proposes that postoperative ERCP appears to be associated with greater health care cost and longer LOS, and suggests that LCBDE is more efficient and preferable when surgical proficiency is available (NIH 2002).

 The same previous principle of prefering single stage procedures is echoed in a case series of 505 pateints treated by LCBDE. The LCBDE has the advantage over preoperative ERCP because it is a one-stage procedure. However, these two techniques are not opposite but complementary, each having its own indi- cations. The LCBDE is particularly indicated in clinically fit patients for laparoscopy because it is a safe procedure in terms of short-term outcome and late sequelae. Any time it is feasible, TC-LCBDE is preferable to choledochotomy because of its lower rate of complications and its shorter length of hospital stay (Berthou et al., 2007).

Laparoscopic cholecystecomy combined with intraoperative ERCP was compared with preoperative ERCP followed by laparoscopic cholecystecomy for management of preoperatively known gall bladder stones and CBD stones. There were no significant difference in postoperative retained stones, or complications. Laparoscopic cholecystecomy and intraoperative ERCP appeared to be an attractive option in centers that are able to provide a team approach to the management of choledocholithiasis. This approach is a single-stage treatment that reduces the hospital stay and costs. It also eliminates the need to return to the operating room following technical failure of ERCP (Elgeidie et al., 2011).

Another point of view regarding the cost of treatment was discussed by Brown et al., 2011 assuming that both LCBDE and ERCP with sphincterotomy are equally effective, then it is worthwhile to determine which costs less. The most cost-effective treatment strategy for the majority of patients with symptomatic cholelithiasis is LC with routine IOC. If stones are detected, LCBDE should be forgone and the patient referred for ERCP (Brown et al., 2011).

ERCP versus open surgery

Open bile duct surgery is superior to open cholecystectomy plus ERCP in its ability to achieve CBD stone clearance.However, The use of ERCP necessitates increased number of procedures per patient. The evidence would suggest that when a surgeon is required to perform an open cholecystectomy in a patient with CBD stones, then surgical duct clearance is, at the least, a worthy option (Martin et al., 2006) .

 

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