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Gallstones and gallbladder disease - Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy)

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of gallstones.

Alternative Names

Cholecystitis; Choledocholithiasis; Bile duct stones

Open or Laparoscopic Common Bile Duct Exploration (Choledocholithotomy):

Laparoscopic Exploration and Cholangiography

Surgeons are now increasingly using laparoscopy with cholangiography instead of ERCP when common duct stones are suspected. Laparoscopy with cholangiography should only be done in centers with expertise in this procedure. Potential indications include.

  • An alternative to ERCP before gallbladder surgeries, when there is high suspicion of common bile duct stones.
  • During gallbladder surgeries when common duct stones are detected or highly suspected.

The procedure usually involves the following steps:

  • The initial approach is the same as with laparoscopic cholecystectomy. Small incisions, one or two 10 - 12 mm (around half an inch) and three 5 mm (about a fifth of an inch), are made in the abdomen.
  • A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiography. Cholangiography also reduces the risk for injury in the common duct.
  • If stones are identified, the surgeon inserts a tube with an inflatable balloon to widen the duct.
  • Stones are usually retrieved or withdrawn from the duct either with the use of a balloon or with a tiny basket.
  • If laparoscopy is unsuccessful, ERCP or open surgery is performed.

Experts are debating whether this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective, and should be the first choice of treatment. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.

Open Common Bile Duct Exploration (Choledocholithotomy)

Choledocholithotomy, or common bile duct exploration, is used:

  • To remove large stones
  • When the duct anatomy is complex
  • During or after some gallbladder operations when stones are detected. If the procedure is laparoscopy, surgeon may convert to open procedure, though this happens less often now.
  • When ERCP or laparoscopic procedures are not available.

In this procedure, the doctor carries out open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a so-called "T-tube" is temporarily left in the common bile duct after surgery and the doctor x-rays the bile duct through the tube 7 - 10 days after surgery, to determine if any stones remain in the duct.

Resources

References

Afdhal NH. Diseases of the Gallbladder and Bile Ducts. In: Goldman L, Ausiello D. (eds.). Cecil Textbook of Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007.

Buch S, Schafmayer C, Völzke H, et al. A genome-wide association scan identifies the hepatic cholesterol transporter ABCG8 as a susceptibility factor for human gallstone disease. Nat Genet. 2007;39(8):995-999.

Dray X, Joy F, Reijasse D, et al. Incidence, risk factors, and complications of cholelithiasis in patients with home parenteral nutrition. J Am Coll Surg. 2007;204(1):13-21.

Grünhage F, Acalovschi M, Tirziu S, et al. Increased gallstone risk in humans conferred by common variant of hepatic ATP-binding cassette transporter for cholesterol. Hepatology. 2007;46(3):793-801.

Gurusamy, KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database Syst Rev. 2007;(1):CD006230.

Ito K, Ito H, Whang EE. Timing of Cholecystectomy for Biliary Pancreatitis: Do the Data Support Current Guidelines? J Gastrointest Surg. 2008 Jul 18 [Epub ahead of print].

Kuo KK, Shin SJ, Chen ZC, et al. Significant association of ABCG5 604Q and ABCG8 D19H polymorphisms with gallstone disease. Br J Surg. 2008;95(8):1005-1011.

Myers JA, Fischer GA, Sarker S, et al. Gallbladder disease in patients undergoing laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2005;1(6)561-563.

Portenier DD, Grant JP, Blackwood HS, et al. Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2007; 3(4):476-479.

Rosing DK, de Virgilio C, Yaghoubian A, et al. Early cholecystectomy for mild to moderate gallstone pancreatitis shortens hospital stay. J Am Coll Surg. 2007;205(6):762-766.

Strasberg SM. Acute calculous cholecystitis. N Engl J Med. 2008;358(26):2804-2811.

Tsai CJ, Leitzmann MF, Willett WC, et al. Fruit and vegetable consumption and risk of cholecystectomy in women. Am J Med. 2006;119(9):760-767.

Tsai CJ, Leitzmann MF, Willett WC, et al. Heme and non-heme iron consumption and risk of gallstone disease in men. Am J Clin Nutr. 2007;85(2):518-522.

Williams EJ, Green J, Beckingham I, et al. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008;57(7):1004-1021.

  • Reviewed last on: 9/30/2008
  • Reviewed by: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
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