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PO Box 2345, Beijing 100023, China
World J Gastroenterol
2006 May 28; 12(20): 3162-3167www.wjgnet.com
World Journal of Gastroenterology
ISSN 1007-9327wjg@wjgnet.com © 2006 The WJG Press. All rights reserved.
Choledocholithiasis: Evolving standards for diagnosis andmanagement
Marilee L Freitas, Robert L Bell, Andrew J Duffy
Marilee L Freitas, Robert L Bell, Andrew J Duffy,
Departmentof Surgery, Yale University School of Medicine, 40 Temple Street,Suite 3A, New Haven, CT 06510, United States
Correspondence to:
Andrew J Duffy, MD, Department of Surgery, Yale University School of Medicine, 40 Temple Street,Suite 3A, New Haven, CT 06510,United States. andrew.duffy@yale.edu
Cholelithiasis, one of the most common medical condi-tions leading to surgical intervention, affects approxi-mately 10 % of the adult population in the United States.Choledocholithiasis develops in about 10%-20% of pa-tients with gallbladder stones and the literature suggeststhat at least 3%-10% of patients undergoing cholecys-tectomy will have common bile duct (CBD) stones.CBD stones may be discovered preoperatively, intraop-eratively or postoperatively Multiple modalities are avail-able for assessing patients for choledocholithiasis includ-ing laboratory tests, ultrasound, computed tomographyscans (CT), and magnetic resonance cholangiopancrea-tography (MRCP). Intraoperative cholangiography duringcholecystectomy can be used routinely or selectively todiagnose CBD stones.The most common intervention for CBD stones isERCP. Other commonly used interventions include intra-operative bile duct exploration, either laparoscopic oropen. Percutaneous, transhepatic stone removal othernovel techniques of biliary clearance have been devised.The availability of equipment and skilled practitionerswho are facile with these techniques varies among insti-tutions. The timing of the intervention is often dictatedby the clinical situation.
© 2006 The WJG Press. All rights reserved.
Key words:
Choledocholithiasis; Laparoscopy; Diagnosis;Treatment; Cholangiogram
Freitas ML, Bell RL, Duffy AJ. Choledocholithiasis: Evolvingstandards for diagnosis and management.
World J Gastroenterol 
2006; 12(20): 3162-3167
Symptomatic gallstone disease is a very common indica-tion for abdominal surgery. It is estimated that around500 000 cholecystectomies are performed a year in theUnited States. Gallstones, alone, are rarely an indicationfor surgery, but 10% of the adult population are believedto carry them. Furthermore, up to one-third of the popu-lation over 70 years of age will have gallstones. Gallstoneformation is a multifactorial process but is undoubtedly associated with family history, diabetes mellitus, pregnancy,obesity, signi
cant weight loss, and hemolytic diseases. Asmany as 35% of patients with gallstones will ultimately be-come symptomatic and require cholecystectomy 
.Common indications for surgical treatment for chole-lithiasis include biliary colic, acute cholecystitis, gallstonepancreatitis, and other presentations of choledocholithiasisincluding bile duct obstruction and cholangitis. Other rela-tive indications include gallstones in patients undergoing splenectomy for hemolytic anemia, high risk patients inthe pretreatment phase for other conditions such as bonemarrow transplant. Cholecystectomy is no longer routinely performed for asymptomatic gallstones in those undergo-ing bariatric surgery or aortic surgery.Common bile duct (CBD) stones may be discoveredpreoperatively, intraoperatively or postoperatively. Thestandard preoperative workup for patients presenting withsymptoms attributable to cholelithiasis includes liver func-tion tests, and abdominal ultrasound. These tests, com-bined with clinical exam and history, constitute the entire workup for most patients. Abnormalities in these tests may suggest the presence of choledocholithiasis. Choledocholi-thiasis may occur in up to 3%-10% of all cholecystectomy patients
, or as high as 14.7% in some series
. This in-cludes some patients without classic preoperative
ndingssuggestive of choledocholithiasis. Of these asymptomaticpatients, it is believed about 15% will eventually becomesymptomatic
and require further interventional treat-ment.Since the advent of routine laparoscopic cholecystecto-my, the debate has continued about the utility of intraoper-ative bile duct assessment, primarily with cholangiography or intraoperative ultrasonography. This debate continuesto some degree, with most surgeons either selectively orroutinely evaluating the bile duct intraoperatively. A smallersubset relies only on preoperative assessment tools, includ-ing magnetic resonance cholangiopancreatography (MRCP)
John Geibel, MD, Dsc and Walter Longo, MD,
Series Editors 
and endoscopic retrograde cholangiopancreatography (ERCP), as a complement to routine laboratory and imag-ing studies. The most common intervention for commonbile duct (CBD) stones is ERCP. Other procedures forCBD stone extraction include percutaneous, transhepaticstone removal and intraoperative CBD exploration, wheth-er laparoscopic or open. The availability of equipment andskilled practitioners who are facile with these techniques varies among institutions. The timing of the interventionis often dictated by the clinical situation.
Diagnosis of choledocholithiasis is not always straight-forward and clinical evaluation and biochemical tests areoften not suf 
ciently accurate to establish a
rm diagnosis.Imaging tests, particularly abdominal ultrasound, are usedroutinely to confirm the diagnosis. Liver function tests(LFT) can be used to predict CBD stones
. Elevatedserum bilirubin and alkaline phosphatase typically re
ectbiliary obstruction but these are neither highly sensitivenor speci
c for CBD stones. Excepting obvious jaundice,a raised GGT level has been suggested to be the mostsensitive and speci
c indicator of CBD stones. A value of greater than 90 U/L has been proposed to indicate a highrisk of choledocholithiasis
. However, laboratory datamay be normal in as many as a third of patients with cho-ledocholithiasis, warranting further evaluation of the CBDby imaging studies to clarify the diagnosis.In order to help select from the various diagnostic andtherapeutic options, patients may be classified preopera-tively into high, moderate or low risk groups. The high risk (> 50% risk) group includes those patients with obviousclinical jaundice or cholangitis, choledocholithiasis or adilated CBD on ultrasonography. Patients with a history of pancreatitis or jaundice, elevated preoperative bilirubinand alkaline phosphatase levels or multiple small gallstonescarry a moderate (10%-50%) risk of choledocholithiasis.Patients with large gallstones, without a history of jaundiceor pancreatitis and with normal liver function tests areconsidered unlikely to have CBD stones and therefore atlow risk (< 5%)
.The transabdominal ultrasound examination (US) is themost commonly used screening modality. In patients whopresent with symptoms attributable to gallstone disease,US may be the only radiologic study ordered. It has theadvantages of being widely available, non-invasive, andinexpensive. Ultrasonography, however, is highly operatordependent, but it can provide useful information in ex-perienced hands. For a diagnosis of cholecystitis, in mostcircumstances, gallbladder stones need to be visualized. The sonographic presence of wall thickening, perichole-cystic
uid, and a Murphy’s sign, may be helpful but arenot required for a diagnosis of acute cholecystitis. Theultrasonographer should routinely report indirect informa-tion suggestive of the presence or absence of CBD stones,speci
cally the CBD diameter or any signs of intrahepaticbile duct dilation. The sensitivity of US for detecting bili-ary dilatation, as reported in various studies, varies from 55to 91 percent
. A CBD diameter of greater than 6 mm onUS is associated with a higher prevalence of choledocholi-
Freitas ML
et al.
Diagnosis and management of choledocholithiasis 3163
.Computed tomography (CT) may have some role indiagnosis of gallstone disease and choledocholithiasis.Many patients presenting with acute abdominal pain willundergo a diagnostic CT scan as part of the acute workup. A diagnosis of acute cholecystitis may be evident based onsigns of gallbladder inflammation. Cholelithiasis may bedetected on CT
and often the diameter of the CBD canbe measured. In the clinical setting, US may not be neces-sary for preoperative evaluation if the CT scan providesthis information. The role of helical CT cholangiographis still in evolution, particularly in the United States. Intra- venously administered contrast agents, combined with highresolution helical scans and three dimensional reconstruc-tions that can be very useful in diagnosing choledocholi-thiasis
. The sensitivity of this technique can be as highas 95.5%
. This technique is not widely utilized in the U.S.as the available contrast agents often cause signi
cant nau-sea on administration. The availability of MRCP also limitsthe need for this modality.MRCP has emerged as an accurate, non-invasive diag-nostic modality for investigating the biliary and pancreaticducts
and has been recommended in some circles asthe preoperative procedure of choice for the detection of CBD stones
. MRCP provides excellent anatomic de-tail of the biliary tract and has a sensitivity of 81%-100%and a speci
city of 92%-100% in detecting choledocho-lithiasis
. The accuracy of MRCP in diagnosing CBDstones is comparable with that of ERCP and IOC
. Itthus avoids the need for a potentially high risk, invasiveprocedure in more than 50% of patients, allowing selec-tive use of ERCP or surgical CBD exploration in thosepatients who require a therapeutic intervention. Theseresults have led some practitioners to consider MRCP thenew gold standard for biliary imaging 
. MRCP may,however, miss stones less than 5 mm in diameter. MRCPis an expensive option that requires significant expertisefor interpretation; this modality may not always be readily available.Endoscopic techniques such as endoscopic ultrasound(EUS) and ERCP can also be useful tools in preoperativediagnosis and, in the case of ERCP, management of cho-ledocholithiasis. Both procedures are more invasive thanstrictly radiologic techniques, and carry the low, but inher-ent risks of upper gastrointestinal tract endoscopy. ERCPalso carries the risks associated with biliary instrumenta-tion, such as pancreatitis. Endoscopic ultrasound (EUS)can been used to evaluate the CBD and identify calculi.Studies comparing the accuracy of EUS to US, CT andERCP for detecting choledocholithiasis show a sensitiv-ity of EUS ranging from 88%-97%, with a speci
city of 96%-100%
. This is comparable to ERCP and avoids therisks of pancreatitis, cholangitis and radiation exposure
. The role of EUS, however, is not well established espe-cially when cost and availability of less invasive modalitiessuch as MRCP are considered. EUS may be combined with ERCP at the same endoscopy session if biliary calculiare identi
ed, allowing it to be a bridge to therapeutic in-tervention.ERCP has been the gold standard for preoperative diag-nosis of CBD calculi. When compared to other tests such
as ultrasonography and MRCP, ERCP has the advantageof providing a therapeutic option when a CBD stone isidentified. Stone retrieval and sphincterotomy has sup-planted surgical treatment of choledocholithiasis in many institutions
. Successful cholangiography by an experi-enced endoscopist is achieved in greater than 90% of pa-tients. Complications associated with ERCP can be as highas 15% and include pancreatitis, cholangitis, perforation of the duodenum or bile duct, and bleeding. These individualcomplications can occur in 5%-8% of patients. The mor-tality rate from ERCP is 0.2%-0.5%
Since laparoscopic cholecystectomy became a routine pro-cedure in the early 1990’s, debate has continued about therole of intraoperative bile duct assessment. The interest inintraoperative cholangiography (IOC) came from both thedesire to detect CBD stones and to potentially identify any bile duct abnormalities, including iatrogenic injuries at thetime of surgery. Routine cholangiography is not generally considered to be the standard of care but still has its pro-ponents
. Most surgeons selectively evaluate the bile ductintraoperatively. A smaller subset relies only on preopera-tive assessment tools including magnetic resonance chol-angiopancreatography (MRCP) and endoscopic retrogradecholangiopancreatography (ERCP) as a complement toroutine laboratory and imaging studies.Intraoperative cholangiography can be a useful tool toidentify choledochal calculi but its application remains con-troversial. Proponents often believe that IOC enables clearde
nition of the biliary tree anatomy 
, thus reducing the risk of bile duct injury during cholecystectomy. Moststudies on the subject show no signi
cant difference in therates of ductal injury between routine and selective IOC.Routine IOC has been found to yield little bene
t over theselective approach in the detection of symptomatic CBDstones
Cholangiography is a relatively straight forwardprocedure to perform. It does add to the operative time,approximately an additional 15 min
, but surgeon andoperative team experience can minimize this. Dynamic
uoroscopic imaging is the technique of choice and canprovide a speci
city and sensitivity of 94% and 98%, re-spectively, in experienced hands
. This technique may besomewhat less sensitive for patients presenting with biliary pancreatitis
. A complete IOC should demonstrate thecannulation of the cystic duct,
lling of the left and righthepatic ducts, CBD and common hepatic duct diameter,the presence or absence of 
lling defects in the biliary tree,and free
ow of contrast into the duodenum (Figure 1).Obstruction or other biliary abnormality should be sus-pected if these
ndings are not clear. The overall safety pro
le of IOC is very good. The inci-dence of pancreatitis, in contrast to ERCP, is negligible
. The reliability, ease to perform, and low complication rateof IOC suggest that, at least in cases where choledocho-lithiasis is not proven, IOC during a cholecystectomy is abetter choice than preoperative ERCP assessment of thebile ducts. More recently intraoperative ultrasonography 
3164 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol May 28, 2006 Volume 12 Number 20
of the CBD during laparoscopic cholecystectomy hasbeen shown to satisfactorily demonstrate stones and thebiliary tree. Use of intraoperative ultrasound requires asigni
cant learning curve, but in experienced hands takesless operative time than traditional IOC
. Laparoscopicultrasound compares well with intraoperative cholangiog-raphy. With a sensitivity of 96% and a speci
city of 100%,and the advantages of saved time and lack of radiation,intraoperative ultrasound may be a superior diagnostic mo-dality when compared to IOC
. The use of intraoperativelaparoscopic ultrasound is limited by the availability of equipment and surgeon training and experience. Effortsto incorporate ultrasonography training in to surgical resi-dency curricula should aid its acceptance and use. When CBD stones are detected intraoperatively, a sur-geon must make a clinical decision on how to proceed. This decision is often dictated by the availability of equip-ment, surgeon preference and skill, and the availability of ERCP at a facility. Available options include laparoscopicCBD exploration, intraoperative ERCP, open CBD explo-ration, or postoperative therapy. Many surgeons are reluc-tant to proceed with an open procedure when other, lessinvasive, options are generally available. However, a deci-sion to delay therapy to the postoperative period risks en-countering procedural dif 
culties that preclude endoscopictherapy. Options for intraoperative CBD clearance include variations of laparoscopic exploration. Laparoscopic CBDexploration is most commonly performed with acholedo-choscope. The scope, attached to a second video cameraand light source, is inserted into the CBD
either thecystic duct (Figure 2) or
a choledochotomy. Placementof the choledochoscope directly into the CBD
a cho-ledochotomy is generally reserved for patients with ductsdilated to greater than 6 mm in diameter on cholangio-gram
. A continuous saline infusion through the choledo-choscope dilates the duct and clears debris. CBD stonescan be directly visualized (Figure 3) and instrumented.Between 66 and 82.5% of laparoscopic CBD explorationscan be performed via the cystic duct
. In experiencedhands, the CBD clearance rate is as high as 97%
. In onelarge series of laparoscopic CBD exploration, the overallmorbidity rate of this procedure is approximately 9.5%, with a 2.7% retained stone rate
. These data are equivalentto the experience with ERCP. An alternate technique of laparoscopic CBD clearanceinvolves stone extraction under fluoroscopic guidance.
Figure 1
thecystic duct demonstratingproximal biliary dilation andtwo filling defects in theCBD (Arrows).

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