The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial.
Several diagnostic and therapeutic strategies have been suggested.
These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography.
Dr Katz and colleagues from Victoria, Australia undertook a study in order to evaluate the efficacy of selective ERCP in detecting common bile duct stones in patients with cholelithiasis before laparoscopic cholecystectomy.
The researchers carried out a prospective study including 427 patients with cholelithiasis who presented during a 6-year period.
The research team assessed participants on a selective basis with ERCP for suspected common bile duct stones before laparoscopic cholecystectomy.
The clinicians carried out ERCP if the patient had any of the following criteria: a dilated common bile duct on ultrasound, gallstone pancreatitis, or abnormal liver function tests.
Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken.
|The most useful predictor of CBD stones on ERCP is the presence of a dilated common bile duct with abnormal liver function tests|
On the basis of selective criteria, the clinicians performed ERCP on 41 patients with confirmed common bile duct stones in 22 cases.
The researchers found that the most useful predictor of CBD stones on ERCP was the presence of a dilated common bile duct in association with abnormal liver function tests.
The research team noted that in this situation, common bile duct stones were identified in 14 of 17 cases.
Abnormal liver function tests alone had a sensitivity of 50 % (four of eight). All other parameters used in isolation had a lower detection rate.
During a median follow-up period of 6 years, six of 386 patients with initially normal imaging and biochemical tests presented again with retained stones.
Clinicians successfully managed all cases by ERCP and sphincterotomy and there were no major complications.
Dr Katz concluded, "Preoperative selective ERCP is effective in detecting clinically significant CBD stones."
"However, there is a high false-negative rate when a single criterion is used to guide therapy."
"Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs."