COMMENTARY

Which Technique Is Best for Gallstones With Biliary Duct Calculi?

Albert B. Lowenfels, MD

Disclosures

September 06, 2018

What is the best way to manage patients who, in addition to gallstones, have common bile duct stones? In a paper published in JAMA Surgery ,[1] the authors performed a systematic review and analysis of 20 randomized trials (2489 patients) comparing laparoscopic cholecystectomy (LC) combined with four separate techniques for removing the bile duct stones:

  1. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC as two separate procedures;

  2. LC plus laparoscopic common bile duct exploration;

  3. LC plus intraoperative ERCP—the "rendezvous" technique; or

  4. LC plus postoperative ERCP.

Endoscopic retrograde cholangiopancreatography.

Overall mortality was low (n = 7), and the frequency of various complications varied by the type of procedure used to clear stones from the biliary tract. With respect to avoiding postoperative pancreatitis, preoperative ERCP/LC was the worst combination, whereas combined LC plus laparoscopic common bile duct exploration had the highest probability of a bile leak. The rendezvous procedure gave the best overall results and was the authors' choice for best overall results.

Viewpoint

Although there is near uniform agreement about LC being the best procedure for managing gallstones, managing the combination of gallstones and bile duct stones has been controversial. Mortality rates for biliary tract surgery are low, so the choice of procedure for removal of associated bile duct stones depends on the frequency of complications.

However, as this report illustrates, different bile duct procedures have different complications, making it difficult to select the most advantageous procedure. It is reassuring that the popular rendezvous procedure, used in about one quarter of all reported patients in this study, gave the best overall results.

A recent Cochrane report comparing the rendezvous technique with preoperative ERCP and LC suggested that the rendezvous approach may be superior, but concluded that because of the poor quality of evidence, no firm conclusions could be drawn.[2] The final operative choice may depend on locally available expertise.

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