Management of common bile duct stones (choledocholithiasis) and its complications (part 2)

Common bile duct stones (CBDS) is a complication of gallbladder lithiasis that may or may not be symptomatic. Once discovered in preoperative imaging, management depends on the context. Three options exist: observation (due to possible spontaneous evacuation of the small CBDS), extraction by endoscopic sphincterotomy (potentially risky, particularly in an asymptomatic patient), or surgical treatment (cholecystectomy, with CBD exploration or simple transcystic biliary drainage). In cases of intraoperative discovery (by cholangiography), strategy depends mainly on CBD diameter. With a small CBD, conservative treatment with transcystic drainage is possible, followed six weeks later by an evaluation by cholangiography. With a large CBD, surgical extraction or combined endoscopic treatment can be considered as options during the same operation. For symptomatic CBDS, there are two strategies, neither of which has shown superiority to the other: one-stage: combined surgical-endoscopic or exclusively surgical treatment; two-stages: extraction by endoscopic sphincterotomy followed by cholecystectomy, requiring two separate anesthetic procedures. In the event of CBDS discovered after cholecystectomy, ERCP is the reference treatment. The main complications of CBDS are: cholangitis, a medical emergency necessitating treatment (in accordance with the Tokyo guidelines) including early antibiotherapy and rapid biliary drainage in the moderate and severe forms, ideally by endoscopic sphincterotomy; acute biliary (lithiasic) pancreatitis, for which endoscopic sphincterotomy is indicated only in the event of associated cholangitis or persistent biliary obstruction; surgery is limited to complicated forms, particularly in cases of infected pancreatic necrosis after failed endoscopic and/or radiological drainage. Early cholecystectomy during the same hospitalization is recommended for mild forms.