What is the management of choledocholithiasis?

Management of Choledocholithiasis

The mainstay of therapy for choledocholithiasis is endoscopic biliary sphincterotomy and stone extraction during ERCP, with a reported success rate of 90%. 1

Initial Assessment and Management

• Choledocholithiasis affects approximately 10% of patients with gallstone disease and requires intervention even when asymptomatic due to risks of obstructive jaundice, cholangitis, acute pancreatitis, and potentially secondary biliary cirrhosis 1
• Initial medical management is indicated to stabilize hemodynamic status and treat local and systemic infections in cases of acute biliary obstruction 1
• In acute cholangitis, biliary decompression is lifesaving and should be performed promptly 1

Diagnostic Approach

• For suspected choledocholithiasis, risk stratification should guide the diagnostic approach 1
• For moderate risk patients, preoperative magnetic resonance cholangiopancreatography (MRCP) or endoscopic ultrasound (EUS) should be performed with sensitivities of 93% and 95% respectively 1
• Intraoperative cholangiography or laparoscopic ultrasound can also be used to evaluate moderate risk patients with similar diagnostic accuracy 1
• High-risk patients should undergo preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound depending on local expertise 1

Therapeutic Options

Endoscopic Management (First-line)

• ERCP with sphincterotomy and stone extraction is the mainstay of therapy with 90% success rate 1
• For large stones (>10-15 mm), lithotripsy or stone fragmentation may be required, with lithotripsy having a 79% success rate 1
• In cases of incomplete stone extraction or severe acute cholangitis, placement of an internal plastic stent ensures adequate biliary drainage 1
• Endoscopic sphincterotomy carries a 6-10% major complication rate, increasing to 19% in elderly patients with a mortality rate of 7.9% 1
• Covered self-expandable metal stents (SEMS) may offer prolonged patency compared to plastic stents, but data are limited 1

Percutaneous Approaches

• Percutaneous transhepatic balloon dilation of the papilla with stone extraction is an alternative with success rates of 95-100% in experienced hands 1
• For difficult cases, a rendezvous technique combining percutaneous and endoscopic approaches can be used 1
• In biliary sepsis where stones cannot be primarily crossed, placement of internal/external or external biliary catheters can be lifesaving 1

Surgical Management

• Surgical common bile duct exploration was historically the procedure of choice but is now generally reserved for when stones cannot be managed non-surgically 1
• Open CBD exploration carries 20-40% morbidity and 1.3-4% mortality 1
• Laparoscopic CBD exploration has grown in popularity with success rates up to 95% and complication rates of 5-18% 1
• For patients undergoing laparoscopic cholecystectomy, laparoscopic CBD exploration may be preferable to endoscopic duct clearance 1
• After repeated failed ERCP attempts, surgical management with choledochotomy and bilioenteric anastomosis provides an effective long-term solution 2

Special Considerations

Pregnancy

• ERCP can be performed during pregnancy for urgent indications such as choledocholithiasis and cholangitis 1
• Ideally, ERCP should be performed during the second trimester as first trimester procedures are associated with poorer fetal outcomes 1
• Pregnancy is an independent risk factor for post-ERCP pancreatitis (12% vs 5% in non-pregnant women) 1
• A multidisciplinary approach involving an advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist is recommended 1

Treatment Algorithm

1. Initial assessment: Evaluate severity, presence of cholangitis, and risk stratification for choledocholithiasis
2. For moderate risk: Perform MRCP or EUS to confirm diagnosis
3. For high risk or confirmed stones: Proceed with ERCP as first-line therapy
4. If ERCP successful: Complete stone clearance with sphincterotomy and extraction
5. If large stones present: Add lithotripsy or fragmentation techniques
6. If incomplete extraction: Place temporary biliary stent
7. If ERCP fails: Consider percutaneous approach or surgical management
8. For patients with cholecystitis: Schedule cholecystectomy after bile duct clearance

Pitfalls and Caveats

• Multiple ERCP attempts before declaring failure may lead to procedure-related complications in up to 23.5% of patients 2
• Recent data suggests that a significant proportion of patients (74.3%) have findings (sludge, small stones <7mm, or negative ERCP) that could potentially be managed with simpler intraoperative interventions 3
• A "surgery-first" approach with laparoscopic cholecystectomy, cholangiogram, and common bile duct exploration may be appropriate for selected patients, offering reduced hospital stays with equivalent morbidity 3
• Endoscopic sphincterotomy carries significantly higher complication rates in elderly patients and should be performed with caution in this population 1