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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