What is the management of choledocholithiasis?

Management of Choledocholithiasis

ERCP with endoscopic sphincterotomy and stone extraction is the first-line treatment for choledocholithiasis, achieving 90% success rates and should be performed within 72 hours when cholangitis or biliary obstruction is present. 1

Initial Stabilization and Risk Assessment

• Immediate biliary decompression is lifesaving in acute cholangitis and should be performed urgently (within 24 hours) in patients with severe sepsis or deteriorating despite antibiotics. 2, 1
• For patients with suspected or proven biliary pancreatitis accompanied by cholangitis or persistent biliary obstruction, perform biliary sphincterotomy and stone extraction within 72 hours of presentation. 2
• Initial medical management focuses on hemodynamic stabilization and treating local/systemic infections in acute biliary obstruction. 1

Diagnostic Strategy Based on Risk Stratification

Moderate-risk patients:

• Perform preoperative MRCP (93% sensitivity) or EUS (95% sensitivity) to confirm diagnosis before intervention. 1
• Alternatively, use intraoperative cholangiography or laparoscopic ultrasound with similar diagnostic accuracy. 1

High-risk patients:

• Proceed directly to preoperative ERCP, intraoperative cholangiography, or laparoscopic ultrasound depending on local expertise. 1

Primary Therapeutic Approach: Endoscopic Management

Standard ERCP technique:

• ERCP with sphincterotomy and stone extraction achieves 90% success in clearing the common bile duct. 1, 3
• This approach is definitively the procedure of choice for post-cholecystectomy patients with choledocholithiasis. 3

For large stones (>10-15 mm):

• Add mechanical lithotripsy or stone fragmentation techniques, which achieve 79% success rates. 1
• Consider endoscopic papillary balloon dilation combined with limited sphincterotomy for stones that cannot be safely extracted with sphincterotomy alone. 2

When complete extraction fails:

• Place an internal plastic stent to ensure adequate biliary drainage, particularly in severe acute cholangitis. 1
• Covered self-expandable metal stents may offer prolonged patency compared to plastic stents, though data are limited. 1

Complication Rates and Special Populations

Elderly patients require particular caution:

• Endoscopic sphincterotomy carries 6-10% major complication rate in general populations. 1
• This increases dramatically to 19% in elderly patients with 7.9% mortality. 1
• Most common serious complications include perforation, hemorrhage, acute pancreatitis, and sepsis. 3

Pregnant patients:

• ERCP can be performed for urgent indications like choledocholithiasis and cholangitis. 1
• Ideally perform during second trimester, as first trimester procedures associate with poorer fetal outcomes. 1
• Pregnancy independently increases post-ERCP pancreatitis risk (12% vs 5% in non-pregnant women). 1
• Require multidisciplinary team including advanced endoscopist, maternal-fetal medicine physician, neonatologist, obstetrician, and anesthesiologist. 1

Alternative Approaches When ERCP Fails or Is Unavailable

Percutaneous transhepatic approach:

• Percutaneous transhepatic balloon dilation with stone extraction achieves 95-100% success rates in experienced hands. 2, 1
• Technique involves percutaneous access, balloon dilation of papilla of Vater, and pushing stones into duodenum with Fogarty balloon. 2
• For stones >15 mm, perform basket lithotripsy before balloon dilation. 2
• Major complication rate is 6.8%, including cholangitis, biloma, hematoma, CBD perforation, and bile peritonitis. 2

Rendezvous technique for difficult anatomy:

• Combines percutaneous and endoscopic approaches when papilla is difficult to cannulate endoscopically. 2, 1
• Percutaneous guidewire is navigated into small bowel and snared by endoscopist to facilitate cannulation. 2
• Successful in nearly all cases when standard ERCP fails. 2

For nondilated biliary ducts:

• Percutaneous access through the gallbladder provides alternative decompression route when intrahepatic ducts are not dilated. 2

Surgical Management: Reserved for Refractory Cases

Laparoscopic CBD exploration:

• Now preferred over open surgery with 95% success rates and 5-18% complication rates. 2, 1
• Generally indicated when CBD is wide (>9 mm) to avoid subsequent stricture development. 2
• For patients undergoing laparoscopic cholecystectomy, laparoscopic CBD exploration may be preferable to separate endoscopic duct clearance. 2, 1

Open CBD exploration:

• Reserved only when stones cannot be managed non-surgically. 2, 1
• Carries 20-40% morbidity and 1.3-4% mortality. 2, 1
• May fail to clear duct of all stones. 2

One-Stage vs Two-Stage Treatment for Concurrent Gallbladder and CBD Stones

One-stage treatment (Rendez-vous technique) offers advantages:

• Equivalent success rates, morbidity, stone clearance, and mortality compared to two-stage approach. 4
• Significantly shorter hospital stay and greater cost benefits. 4, 5
• Reduces postoperative acute pancreatitis and overall complications. 5
• Avoids second invasive procedure with greater patient acceptance. 5

Two-stage approach remains common:

• ERCP with sphincterotomy and stone removal followed by laparoscopic cholecystectomy. 4, 5
• May require additional procedures if initial CBD clearance fails. 5

Critical Pitfalls to Avoid

• Do not delay biliary decompression beyond 24 hours in patients with severe sepsis or deteriorating cholangitis despite antibiotics. 2, 1
• Recognize that elderly patients have nearly double the complication rate (19% vs 6-10%) with endoscopic sphincterotomy. 1
• Avoid first trimester ERCP in pregnant patients when possible due to poorer fetal outcomes. 1
• Do not assume all stones can be extracted endoscopically—have backup plan for percutaneous or surgical approach. 2, 1
• For patients with altered anatomy (Roux-en-Y gastric bypass), refer to centers with advanced endoscopic and surgical capabilities. 2