From the Guidelines
No, a common duct stone cannot be removed with a cholecystotomy, as it does not provide direct access to the common bile duct. Instead, procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LBDE) are recommended for the removal of common bile duct stones (CBDS) 1. The choice of procedure depends on various factors, including the size, shape, and number of stones, as well as the patient's anatomy and the availability of local expertise 1. Some key points to consider when deciding on a procedure for CBDS removal include:
- ERCP with sphincterotomy is a common and effective method for removing CBDS 1
- LBDE can be performed via a transcystic or transductal approach, with the transductal approach being more commonly used 1
- The use of intraductal piezoelectric or laser lithotripsy can increase the success rate of LBDE 1
- Percutaneous transhepatic cholangiography (PTC) may be considered in cases where other procedures are not possible or have failed 1 Overall, the goal of treatment is to remove the CBDS in a safe and effective manner, while minimizing morbidity and mortality, and improving quality of life 1.
From the Research
Removal of Common Duct Stones
- A common duct stone can be removed through various methods, including endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy, laparoscopic common bile duct exploration, and percutaneous transcholecystic common bile duct stone removal 2, 3, 4.
- ERCP with endoscopic sphincterotomy is a valuable therapeutic modality in choledocholithiasis, but it has a reported 15% morbidity, 1% mortality, 5% failure rate, and 5% incidence of late ampullary stenosis 2.
- Laparoscopic common bile duct exploration is a satisfactory direct approach for removing common duct stones, with a high success rate and low morbidity and mortality 2.
- Percutaneous transcholecystic common bile duct stone removal through an existing cholecystostomy access is a safe and effective procedure, with a primary technical success rate of 76% and a clinical success rate of 74% 4.
Cholecystotomy as an Approach
- Cholecystotomy can be used as an exclusive access to remove cystic, common hepatic, and common bile duct stones, with a high success rate and low morbidity 4.
- However, the use of cholecystotomy as an approach for removing common duct stones is not widely discussed in the literature, and more studies are needed to evaluate its efficacy and safety compared to other methods 4.
Alternative Methods
- Endoscopic sphincterotomy plus endoprostheses is a safe and effective method in the management of large or multiple common bile duct stones, with a total stone clearance rate of 94.2% 5.
- Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units 6.
- Advanced extracorporeal or intracorporeal fragmentation techniques, such as mother-baby laser or electrohydraulic lithotripsy, may be necessary for difficult bile duct stones 6.