Actual management of common bile duct stones: a continuous evolving approach

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J.F. GIGOT

Ann. Ital. Chir., LXIX, 6, 1998

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The management of common bile duct stones (CBDS) has
recently changed regarding either a more precise diagnosis of
patients at high-risk to harbor CBDS and either the development
of new therapeutic modalities. In patients with preoperative
predictive suspicion of CBDS, new non-invasive radiologic
and endoscopic investigations are now available, namely
3-D spiral CT-cholangiography and magnetic resonance cholangio-
pancreatography on one hand, and endoscopic ultrasonography
on the other hand. With the development of laparoscopic
surgery, two strategies have emerged in order to maintain
the minimally invasive nature of the procedure : perioperative
endoscopic sphincterotomy or laparoscopic common bile
duct exploration. However, considerable laparoscopic expertise,
advanced and expansive technologies are required to achieve successful
laparoscopic treatment of CBDS. An appropriate intraoperative
strategy is mandatory during laparoscopic common bile
duct exploration, with specific indications for the transcystic route
and for laparoscopic choledochotomy, according to patient’s
biliary anatomy and stone’s characteristics. A preliminary controlled
trial has proved the safety, efficacy and excellent postoperative
results of such approach. However, the best option of
management for patients with CBDS remains open to discussion
and the therapeutic choice should depend on the local
hospital availability of technical expertise.

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