From the Guidelines
The recommended treatment for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, which has a reported success rate of 90% 1. This procedure allows direct visualization of the bile duct, removal of stones, and creation of a wider opening at the sphincter of Oddi to facilitate stone passage. Prior to ERCP, patients typically receive antibiotics if infection is suspected, with regimens such as piperacillin-tazobactam 3.375g IV every 6 hours or ciprofloxacin 400mg IV twice daily plus metronidazole 500mg IV every 8 hours. Pain management with NSAIDs or opioids may be necessary. For patients who are poor candidates for ERCP, alternative approaches include percutaneous transhepatic cholangiography (PTC), laparoscopic common bile duct exploration, or in some cases, dissolution therapy with ursodeoxycholic acid. Following successful stone removal, cholecystectomy is recommended if the gallbladder is still present to prevent recurrence. ERCP is preferred over surgical approaches due to its lower morbidity and mortality rates, especially in patients with acute cholangitis or severe comorbidities, as supported by the increasing trend of ERCP utilization from 75.2% to 96.1% in the management of choledocholithiasis between 1998 and 2013 1. Some key points to consider in the treatment of choledocholithiasis include:
- The risk of developing obstructive jaundice, cholangitis, acute pancreatitis, and potentially secondary biliary cirrhosis if left untreated
- The importance of initial medical management to stabilize hemodynamic status and treat local and systemic infection
- The role of ERCP as the mainstay of treatment for choledocholithiasis, with a high success rate and lower morbidity and mortality rates compared to surgical approaches.
From the Research
Treatment Options for Choledocholithiasis
- Endoscopic retrograde cholangiopancreatography (ERCP) is the first line treatment for choledocholithiasis 2
- Surgical treatment is applied when ERCP fails, and it provides a highly effective long-term solution 2
- A combined endoscopic-laparoscopic technique can be used for the management of cholecysto-choledocholithiasis in a single-step procedure 3
- Endoscopic management of acute cholangitis as a result of common bile duct stones is effective and can be achieved by ERCP, balloon enteroscopy-guided biliary drainage, or endoscopic ultrasound guided-biliary drainage 4
Timing of ERCP and Laparoscopic Cholecystectomy
- The timing of ERCP in patients with suspected choledocholithiasis can be either before or after laparoscopic cholecystectomy (LC) 5
- Performing ERCP after LC with a positive intraoperative cholangiogram can eliminate many unnecessary preoperative endoscopic studies 5
- Routine preoperative ERCP is not indicated in children with suspected choledocholithiasis, as the natural history of the disease is spontaneous passage of stones through the papilla 6
Complications and Outcomes
- Post-ERCP complications, such as pancreatitis, can occur, but the risk can be minimized with proper technique and patient selection 3, 4
- Surgical treatment for choledocholithiasis following repeated failed ERCP has a high success rate, but can be associated with major post-operative complications 2
- The outcome of treatment for choledocholithiasis is generally good, with low rates of recurrence and complications, especially when treated with a combined endoscopic-laparoscopic approach 3