Cholelithiasis Plus Choledocholithiasis: ERCP First, What Next?

  • David L. Carr–Locke
    Address requests for reprints to: David L. Carr-Locke, MB, BChir, DRCOG, FRCP, FACG, Director of Endoscopy, Brigham & Women’s Hospital, Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts 02115.fax: (617) 264-5171.
    Director of Endoscopy, Brigham & Women’s Hospital, Associate Professor of Medicine, Harvard Medical School, Boston, Massachusetts
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      When patients present with the combined problem of gallstones in the gallbladder and bile duct simultaneously, there are 2 questions to answer: (1) what is the best method for clearing the bile duct and (2) what should be done with the gallbladder? The sequential options are (1) laparoscopic cholecystectomy with laparoscopic bile duct exploration; (2) laparoscopic or open cholecystectomy followed by postoperative ERCP; (3) preoperative ERCP followed by cholecystectomy (laparoscopic or open); (4) open cholecystectomy with open exploration of the bile duct; (5) ERCP and no cholecystectomy and, in special circumstances; (6) a range of additional and much less commonly used surgical and nonsurgical techniques such as percutaneous cholecystostomy, percutaneous access to the bile duct including percutaneous cholangioscopy, techniques for Mirizzi syndrome, management of hepatolithiasis and approaches to recurrent stones after biliary and nonbiliary upper gastrointestinal surgery. It is unlikely that one option will be appropriate for all clinical circumstances in all centers in all countries since the variables of disease states, patient demographics and risk stratifications, available endoscopic, radiologic and surgical expertise, patient preferences, and healthcare economics will all have significant influences on practice.
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      Linked Article

      • Cholecystectomy or Gallbladder In Situ After Endoscopic Sphincterotomy and Bile Duct Stone Removal in Chinese Patients
        GastroenterologyVol. 130Issue 1
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          Background & Aims: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ.Methods: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management.
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