Choledocholithiasis, stones in common bile duct, is a commonly associated diagnosis in patients presenting with biliary disease with an estimated incidence of up to 15%.1 However, this incidence is likely underestimated as some stones may resolve spontaneously by the time diagnostic imaging is performed. The majority of choledocholithiasis originates from the gallbladder, but in some instances, primary stones can form de novo within the hepatic or common bile ducts, even in the absence of gallbladder. These are usually found in patients of East Asian ethnicities or with biliary stasis, such as in cystic fibrosis or with periampullary diverticula. The diagnosis of choledocholithiasis is based on the constellation of presenting symptoms, physical examination findings, biochemical markers, and imaging findings. Once choledocholithiasis is highly suspected or diagnosed, proceeding with endoscopic biliary clearance is the most common practice pattern in the United States.2 However, surgical approaches with concomitant intraoperative duct clearance are safe and effective options when expertise is available.

DIAGNOSIS History and Physical

The most typical presenting signs of choledocholithiasis are identical to those with acute cholecystitis or symptomatic cholelithiasis: crampy right upper quadrant or epigastric pain and nausea or vomiting. Additional symptoms, such as jaundice, pruritus, pale-colored stool, and dark colored urine, should raise suspicion for choledocholithiasis. If cholangitis develops due to biliary obstruction, patients may present with signs and symptoms of sepsis including fever, chills, altered mental status, and hypotension, in addition to abdominal pain and jaundice. Physical examination will reveal abdominal tenderness, especially with pancreatitis due to gallstones or with concurrent acute cholecystitis. Recognizing systemic signs of sepsis is critical in the timely diagnosis and management of cholangitis.

Laboratory Markers

Patients that present with elevated liver function tests (LFTs), such as bilirubin, alkaline phosphatase, and/or GGTP, should have suspected choledocholithiasis until proven otherwise. However, it is important to emphasize that laboratory markers may be normal in the setting of asymptomatic choledocholithiasis, especially when the stones are small. In cases presenting with leukocytosis or leukopenia and elevated liver enzymes, the diagnosis of cholangitis should be entertained with expedited imaging and treatment.

Imaging

The most widely used imaging study for biliary disease is transabdominal ultrasound (US), due to its availability and noninvasive nature. Point-of-care ultrasound is another valuable tool in capable hands when diagnostic sonographers are not immediately available. The diameter of the common bile duct (CBD) in millimeters (mm) is roughly 10% of the patient’s age in years, and values that are greater than 2 times normal (>8 mm in most patients) are suggestive of choledocholithiasis. Another imaging modality commonly used is computed tomography (CT). Computed tomography can be useful when broad differential diagnoses exist and for patients presenting with nonspecific symptoms as it shows the overall anatomy of the abdomen. It will reveal biliary dilatation and gallbladder distention, but it may not reveal stones whether in gallbladder or in biliary tree.3 Computed tomography images can also show findings associated with malignancy in the biliary tree, such as masses or regional lymphadenopathy. Even in patients with normal liver enzymes, ductal dilation warrants further investigation.

Magnetic resonance cholangiopancreatography (MRCP) is another noninvasive test with a higher sensitivity (80–90%) and specificity (88–100%) compared with transabdominal ultrasound (sensitivity <50%) for choledocholithiasis.4,5 Although noninvasive, obtaining a timely MRCP can be a challenge and lead to delays in definitive treatment. In addition, it is important to recognize that MRCP may not reveal smaller stones (<6 mm) and those in the periampullary region and provides no therapeutic capability.6 Therefore, if the suspicion for choledocholithiasis is high, we prefer to proceed with a single stage diagnostic and therapeutic approach.

Predictors of Choledocholithiasis

According to the risk stratification proposed by the American Society of Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy, the following characteristics are predictors of choledocholithiasis.7,8 Bilirubin >4 mg/DL, presence of CBD stone or dilated CBD on ultrasound (>6 mm), and clinical features of cholangitis are very strong predictors; hence, proceeding to a method of biliary clearance is recommended. Intermediate risks are abnormal LFTs (bilirubin, 1.8–4 mg/dL), dilated CBD on ultrasound or CT imaging, and older than 55 years. For patients who fall into this intermediate risk group, recommended strategies are endoscopic ultrasound (EUS), MRCP, laparoscopic intraoperative cholangiogram (IOC), or intraoperative ultrasound. Patients with none of the above findings are considered low risk, and they can proceed with cholecystectomy with or without IOC or intraoperative US. Despite the treatment algorithm proposed by the societies, there remains variability in practice patterns regarding suspected choledocholithiasis in the United States.9

ENDOSCOPIC OPTIONS

Endoscopic ultrasound is done in the endoscopy suite with introduction of the ultrasound probe into the duodenum. This can be done with sedation alone rather than with general endotracheal anesthesia. The sensitivity and specificity of EUS are in the upwards of 90% (93–97%), which is higher than US or CT.10 Given the risk of post–endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis is 3% to 10%, EUS is usually performed first as a screening tool, and when positive, endoscopists will proceed with ERCP.11,12

Endoscopic retrograde cholangiopancreatography is usually performed under general anesthesia. The most common position is prone although it can be done with the patient in a supine or left lateral position. Once the side-viewing endoscope is introduced into the second part of the duodenum, the CBD is cannulated with a catheter and a guidewire followed by a sphincterotome to transect the sphincter within the ampulla of Vater, all under endoscopic and fluoroscopic guidance. Once this is performed, stones or sludge in distal CBD are removed. If there is still a filling defect in the CBD, snares and baskets can be used to retrieve these stones. Stents can also be placed into the CBD if it is not completely cleared for two purposes: 1) residual stones can be softened with the stent for easier removal on subsequent ERCPs; and 2) the biliary system can be drained via the stent to prevent obstruction. The success rate of biliary clearance with ERCP ranges from 80 to 100%.8,13 Complications after ERCP include pancreatitis (which is most common), bleeding, perforation, and cholangitis. There should be a high level of vigilance for these complications. Another option to clear the biliary system during the ERCP is endoscopic papillary dilation with 4-mm, 6-mm, or 8-mm diameter balloons. A prospective randomized multi-institutional trial has evaluated the effectiveness of endoscopic papillary balloon dilation.14 The successful biliary clearance rate was similar between the groups (100% in sphincterotomy vs. 99.3% in balloon dilation), and the complications occurred in 12% in sphincterotomy group versus 14.5% in the balloon dilation group, which was not significantly different. Postprocedure pancreatitis, however, was more frequent in the balloon dilation group (10.9 vs. 2.8%, p < 0.045) while hemorrhage was only observed in sphincterotomy group. The rate of successful stone removal and early complications (within 14 days) was similar between endoscopic balloon dilation versus standard sphincterotomy, but stone recurrence was much higher in the balloon dilation group (25% vs. 6%) within a year.13 However, looking at long term outcomes up to 6 years, the recurrence rate was reversed and was higher in the sphincterotomy group (27% vs. 6% in balloon dilation group).

MANAGEMENT OF CONFIRMED OR HIGHLY SUSPECTED CHOLODOCHOLITHIASIS

The management of choledocholithiasis has evolved over the past decade with a growing body of literature that supports single stage therapy (i.e., operative intervention with concomitant ductal clearance) for those with symptomatic disease.15–17 This can be achieved through several intraoperative modalities that will be described in the following sections. Institutional expertise and availability will ultimately dictate which single stage care path is undertaken. For those patients with confirmed biliary obstruction (i.e., choledocholithiasis or gallstone pancreatitis) that have undergone endoscopic biliary clearance successfully, cholecystectomy during the same admission is still recommended. A Cochrane Database review of 5 randomized controlled trials compared outcomes of “wait-and-see group”: those who deferred cholecystectomy versus those who had prophylactic cholecystectomy after endoscopic biliary sphincterotomy.18 The “wait-and-see” group had almost 80% increased risk of mortality compared with the prophylactic group as well as higher rates of recurrent biliary pain, biliary obstructive complications, and repeat ERCP. Thus, we believe that “wait and see” approach be used sparingly in select populations (i.e., elderly with severe comorbidities).

SURGICAL MANAGEMENT Laparoscopic Cholecystectomy With Intraoperative Cholangiogram

Imaging of the biliary tree may still be indicated even after successful biliary clearance as some patients are at risk of residual choledocholithiasis or passing another stone. Two studies have suggested that this incidence ranges from 13% to 33%.19,20 Therefore, it is recommended to consider routine IOCs for patients with confirmed choledocholithiasis even after a successful preoperative ERCP.

The setup for the cholangiogram catheter is important and should be discussed with the surgical technician/circulator preoperatively to eliminate any delays. Intraoperative cholangiogram is performed using either a Kumar or Olsen clamp. A randomized study (KOALA trial) compared the success rate, duration of IOC, and the surgeons’ perceived ease of the instruments. There was no difference in any of these outcomes, and the mean time of IOC using either clamp was between 10 to 11 minutes.21 An extension tubing with a three-way stop cock and two syringes should be attached to the clamp of choice. One syringe (usually 30–50 mL) is filled with saline and the other with contrast (we prefer 50% saline and 50% iso-osmotic contrast). Both syringes need to be completely free of any air bubbles to prevent misinterpretation as filing defects. The catheter also needs to be flushed with saline prior to cannulation into the cystic duct or the infundibulum of the gallbladder. A C-arm fluoroscope should be in the operating room with the sterile drapes, and the operating table should be adjustable to ensure the C-arm can be placed appropriately. The key component while performing an IOC is still to obtain the critical view of safety first to ensure the correct duct is cannulated. If there is any question in biliary anatomy, the infundibulum may also be cannulated, although reflux of contrast into the gallbladder may be a limitation.

When performing an IOC, all the following need to be observed to be considered a negative IOC: 1) no filling defects in the CBD, 2) brisk filling of the duodenum with contrast, and 3) visualization of the right and left intrahepatic ducts without filling defects. Figure 1 is a good example of a positive IOC showing stones in distal CBD and dilated intrahepatic and extrahepatic ducts. It is also important for the surgeon to ensure that the IOC is interpreted correctly.22,23 If there is any question in biliary anatomy, a second opinion from a surgical colleague or consultation with a radiologist is recommended.

Figure 1:

Intraoperative cholangiogram with filling defects in distal CBD (asterisks) and dilated ducts.

Laparoscopic Ultrasound

Aside from the traditional intraoperative cholangiogram, laparoscopic ultrasound (LUS) is another viable option to diagnose choledocholithiasis and to assess the biliary anatomy. The advantages of LUS over IOC are the absence of radiation, shorter operating time, and avoiding cannulation of the biliary tree. Some studies have suggested sensitivity of 95% to 99% and specificity of 94% to 100% of LUS for choledocholithiasis.24,25 Laparoscopic ultrasound can also be utilized multiple times during dissection to safely delineate the tissue planes and relevant anatomy. However, just like any other ultrasound, accuracy heavily depends on the examiners’ proficiency to use the probe and to interpret the images.

Laparoscopic Transcystic CBD Exploration

When IOC or LUS is performed, and the diagnosis of choledocholithiasis is confirmed, methods for stone clearance include: “power flushing” of the CBD after glucagon injection (1–2 mg of IV glucagon, followed by waiting for about 2 minutes), Nitinol basket deployment with stone retrieval via choledochoscopy, or crushing/flushing the stones with balloon dilation of the sphincter. It is also important to consider the following when performing transcystic CBD exploration (CBDE). A standard cholangiogram catheter may be too small and easily kinked or occluded with clips and to accommodate balloons and baskets. A 6-Fr to 8-Fr open-ended ureteral catheter obviates these issues and can accommodate wires and baskets.26

If the power flushing with saline is unsuccessful with persistent filling defects, then threading a Nitinol basket under either fluoroscopic guidance or choledochoscopy can be utilized. If stones are too large to be removed via the transcystic approach, the cystic duct can be dilated with a balloon. If stones are soft and can be crushed with atraumatic graspers or a wire, smaller stones can now be retrieved using the basket or Fogarty balloon (#4-5 Fogarty balloon) or can be flushed into the duodenum. The key limitation of the Fogarty technique is the possibility of pushing the stones into the common hepatic duct, making them difficult to retrieve or injuring the sphincter of Oddi leading to pancreatitis and bleeding. Final cholangiograms need to be done to ensure that all stone fragments are cleared and not in the intrahepatic ducts or common hepatic duct.26

Sequential balloon dilation is another technique that allows for ductal clearance. Once a floppy-tipped guidewire is threaded into the CBD into the duodenum under fluoroscopic guidance, a balloon (6 Fr or 8Fr with various lengths of the balloon 40, 80, and 100 mm) can be used to dilate the sphincter of Oddi up to the diameter of the CBD. It is advisable to place the entirety of the balloon into the duodenum, inflating the balloon, and pulling back gently for accurate positioning. Subsequently, deflating the balloon slightly and retracting it will get the balloon right at the sphincter. The balloon can then be inflated to the full manufacturer’s specifications and held at that pressure for 3 minutes to 5 minutes. Following this, the balloon is retracted back to the cystic duct-CBD junction and the wire is removed. A cholangiogram is shot with the CBD sealed to flush the debris into the duodenum and to prevent flushing the debris into the hepatic ducts.26 This stepwise, catheter-based laparoscopic transcystic CBD exploration approach has been associated with a high success rate of biliary clearance and shorter length of stay compared with cholecystectomy with postoperative ERCP with minimal risk of perioperative complications.27

Using a choledochoscope allows direct visualization of the stones as well as basket retrieval under direct vision. This requires additional placement of another 5 mm trocar in the right upper quadrant. Placing the choledochoscope via the cystic duct may require balloon dilation of the cystic duct. The OR staff needs to set up: 1) a video system to show both the laparoscopic and choledochoscope view and 2) a pressured bag of saline connected to the choledochoscope, similarly to cystoscopy setup to allow for irrigation of the CBD. Once stones are visualized, they are retrieved using the baskets via the working channel. Stones can also be fragmented using the basket under direct visualization, and the fragments can be flushed into the duodenum or retrieved using the basket. A completion cholangiogram is done routinely.

If there are residual stones left in the biliary system that were not able to be cleared using one of the aforementioned techniques, ligating the cystic duct stump with an endoloop is preferable to clips alone as there may be an increased pressure in the biliary system during subsequent attempts at stone retrieval leading to clip failure. For any proximal biliary duct stones that are difficult to access, it is reasonable to abandon further attempts and pursue either intraoperative or postoperative ERCP.

Laparoscopic Common Bile Duct Exploration

The decision to perform laparoscopic choledochotomy over transcystic CBD exploration is usually made based on the IOC findings: small cystic duct (<4 mm), large stones (>6 mm), multiple stones (>5), or when CBD stones are proximal to the cystic duct implantation or in the intrahepatic ducts, and after failure of transcystic CBD exploration.28 The CBD should be at least 7 mm in diameter to reduce postoperative strictures after choledochotomy, and if there is significant inflammation of the CBD, transcystic approaches are preferred.

To perform laparoscopic CBDE, the porta hepatis is exposed by pulling the cystic duct up and laterally, and the peritoneum overlying the supraduodenal CBD is dissected out for about 2 cm. Stay sutures may be placed at either side of the choledochotomy, and the choledochotomy is made in a longitudinal fashion (about 1 cm) using the endoknife and or/endoscopic scissors on the anterior aspect to avoid severing the blood supply coursing at 3 o'clock and 9 o'clock of the CBD. Some surgeons advocate for aspirating bile with a 25G needle prior to cutting on the target structure to ensure that the portal vein is not injured.

Once the CBD is entered, stones visualized through the choledochotomy are removed using atraumatic graspers, and any residual stones in the distal CBD may be pushed out using atraumatic graspers through the choledochotomy or flushed with irrigation. Having a retrieval bag nearby is beneficial to minimize spillage of stones, which may lengthen the operating time. A choledochoscope is passed directly into the proximal bile duct and into the hepatic ducts, which is another advantage of having the choledochotomy. Stone retrieval baskets can then be used to extract any residual stones not evacuated during choledochotomy. Figure 2 shows the picture-in-picture monitor setup with the laparoscopic CBD exposure and choledochoscopic images and the visualized CBD stones.

Figure 2:

PIP setup on the monitor with the choledochoscope introduced into CBD with stones visualized on the choledochoscope. PIP, picture-in-picture.

Regarding approaches to closure of choledochotomy after CBD exploration, there has been controversy about drainage with T-tube versus primary closure. T-tubes are historically used to minimize bile leaks and to provide easy access for to the CBD postoperatively. However, T-tubes cause morbidity, such as possible dislodgement, erosion, bile loss, and pain in the surrounding skin. Cochrane Database reviews of both laparoscopic and open CBDE concluded that routine T-tube drainage is associated with longer operating time and hospital length of stay with no differences in morbidity including bile leaks.29 Another meta-analysis of randomized controlled trials also reached a similar conclusion that primary closure was superior to T-tube drainage after laparoscopic CBD exploration in terms of biliary complications, reoperation, operating time, and postoperative hospital stay.30 For primary closure of the choledochotomy 4-0 or 5-0 monofilament, absorbable sutures are utilized in either a simple interrupted or running fashion (Fig. 3). A surgical drain can be left around the choledochotomy site if there is any concern for bile leak.

Figure 3:

Laparoscopic closure of choledochotomy with absorbable sutures.

If T-tube is utilized to close the choledochotomy site, a cholangiogram via the T-tube is usually performed 24 hours to 48 hours postoperatively. The T-tube can then be clamped if the cholangiogram is normal and will remain in place for another 2 weeks to 4 weeks before removing it. If there is any residual stones present (Fig. 4) or the contrast is not briskly filling the duodenum (suggestive of edema of the papilla), then the T-tube is left open for 1 week to 3 weeks until another repeat cholangiogram. If normal, the tube can be pulled at that time. If residual stones are still present, repeat ERCP by an endoscopist (Fig. 5), or interventional radiology consultation should be obtained for possible interventions via the T-tube.

Figure 4:

Cholangiogram via a T-tube (dark arrow) showing residual intrahepatic duct stones (white arrow) in a patient who underwent cholecystectomy, open CBD exploration, closure of choledochotomy with a T-tube, and surgical drain placement. She underwent ERCP with CBD stent (dotted arrow) placement postoperatively. This cholangiogram via the T-tube was taken 3 weeks postopeartively.

Figure 5: Intrahepatic stones subsequently cleared endoscopically in the patient in Figure 4.Open Versus Laparoscopic CBD Exploration

There has been a debate on the safety and efficacy of the laparoscopic approach in clearing the biliary tree. A systematic review of the literature over the last decade has shown that laparoscopic CBD exploration through both transcystic and transductal approaches is associated with lower morbidity and shorter hospital stay compared with open surgery. The conversion to open surgery was about 5% to 8%, and the transcystic approach was more favorable than the transductal approach with regards to bile leak rates, mean operating time, hospital stay, and morbidity.31 The most common morbidity associated with open common bile duct exploration is wound infection and bile leak in the short term and biliary stricture in the long term. Given the benefits of laparoscopy over open approach, this should be preferred method of intervention when this expertise is available.

Concomitant Cholecystectomy and ERCP

Another single stage option for clearance of choledocholithiasis is a concomitant cholecystectomy and ERCP intraoperatively, which is called a rendezvous technique. Coordinating with an advanced endoscopist is essential (assuming the surgeon does not have these endoscopic skills), which makes this technique less common. Similar to laparoscopic CBDE, this requires a single administration of general anesthesia and shortens hospital stay.32,33 Once the cystic duct is identified, a soft-tipped guidewire can be introduced via the cystic duct into the CBD and into the ampulla; this wire can then be grasped by the snare or a basket by the endoscopist, and the CBD is cannulated. Sphincterotomy can be done, and the CBD stones can be removed with a reported lower incidence of pancreatitis as inadvertent pancreatic duct cannulation and injection of contrast can be prevented.34 A Cochrane review in 2018 attempted to compare traditional two-staged preoperative endoscopic sphincterotomy and stone removal followed by laparoscopic cholecystectomy (LC) versus single-stage rendezvous technique.35 There was insufficient evidence to state the overall morbidity, such as clearance of the bile duct and postoperative pancreatitis. The operating time was longer for those who underwent the rendezvous technique, but the hospital stay was lower in the rendezvous group by about 3 days, which was expected. Another systemic review of these two approaches in 2020 concluded that laparoscopic rendezvous is equivalent to the two-stage procedure in terms of biliary clearance and conversion but is associated with less pancreatitis and shorter hospital stay.36 Therefore, when laparoscopic CBDE expertise is not available, this method is a suitable substitution for single stage ductal clearance and demonstrated equivalence in recent network meta-analysis.15

INTERVENTIONAL RADIOLOGY OPTIONS

Percutaneous transhepatic cholangiography (PTC) is a diagnostic and therapeutic modality offered by interventional radiology under sedation to treat biliary duct obstruction and plays a role when ERCP or surgical intervention may not be feasible or unsuccessful. During a PTC, biliary decompression can be performed with a drain especially for those who are septic and hemodynamically unstable from cholangitis as a temporizing measure. Sphincter dilation can be performed with a balloon to clear the CBD. An advantage for percutaneous approaches is the ability to access the biliary tree in those who have a difficult or altered anatomy, such as periampullary diverticulum, Billroth II gastrectomy, or Roux-en-Y gastrojejunostomy.37 A PTC can also be used to assist in obtaining access to the biliary tree via endoscopy in a method similar to the rendezvous procedure by passing a wire into the biliary tree from above and snaring it with the endoscope. This can allow for duct evaluation in challenging cases mentioned above.

Another option is percutaneous transhepatic cholangioscopic lithotomy, which can be an alternative for clearing CBD stones which cannot be removed successfully using conventional endoscopic methods. In a small retrospective study, 100% of those who had failed endoscopic clearance of the duct were able to have complete stone removal with the percutaneous transhepatic cholangioscopic lithotomy with 6% experiencing hemobilia and percutaneous transhepatic biliary drainage tract disruption.38 Hemobilia was due to shock waves incorrectly focusing on the bile duct, which was treated with epinephrine irrigation and reinsertion of the tube; the tract disruption was with dislodgement of the tube which was treated also with reinsertion of the tube.

Complications from percutaneous approaches include infection (cholangitis, sepsis, abscess), bile leak or biloma, hemorrhage (subcapsular hematoma or pseudoaneurysm), and pneumothorax. Providers caring for patients who have undergone PTC should be aware of these potential complications.

CONCLUSION

Choledocholithiasis presents a common challenge to the acute care surgeon. Advances in both endoscopy and laparoscopic approaches have expanded the options available to treat choledocholithiasis with decreased morbidity to the patient. When expertise is available, single stage methods that provide ductal clearance with gallbladder removal provide the most expeditious route of care without increased morbidity to the patient. A generalized treatment algorithm based upon best available evidence and institutional expertise is provided in Figure 6.

Figure 6:

Treatment algorithm of choledocholithiasis.

AUTHORSHIP

Both authors reviewed the current literature. Both authors prepared, reviewed, and approved the final version of the article.

DISCLOSURE

None of the authors have any conflicts of interest. No external funding was received for this work. Conflicts of Interest: Author Disclosure forms have been supplied and are provided as Supplemental Digital Content (https://links.lww.com/TA/D250).

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