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Invited Commentary |

Clearing Common Bile Duct Stones:  One Size Does Not Fit All ONLINE FIRST

Paul Montero, MD1; Richard D. Schulick, MD, MBA1
[+] Author Affiliations
1Department of Surgery, University of Colorado School of Medicine, Aurora
JAMA Surg. Published online August 13, 2014. doi:10.1001/jamasurg.2014.195
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Möller et al1 report on common bile duct stone (CBDS) incidence, management, and outcomes in a large retrospective cohort analysis. They find a higher rate of unfavorable outcomes when stones are encountered and no measures are taken to address them. Limitations, including the heterogenous metric of unfavorable outcome and the inability to compare or register more than 1 intervention technique, are acknowledged. Ultimately, their findings have very limited effect on the debatable topic of CBDS management. Variables persist in this patient population, including patient selection and preoperative suspicion; routine vs selective cholangiography; preoperative, intraoperative, and postoperative endoscopic retrograde cholangiopancreatography (ERCP); and intraoperative open and laparoscopic management. New diagnostic measures, including magnetic resonance cholangiopancreatography and endoscopic ultrasonography, are more frequently used2 but add cost and extra procedures to the overall management. Routine intraoperative cholangiography is championed by many3 but may result in nontherapeutic interventions in as many as one-third of cases.4 In a compelling study by Collins et al,4 an intraoperative cholangiographic catheter was left in place when stones were found, and repeated cholangiograms at 48 hours and 6 weeks demonstrated normal findings in more than half of the patients, suggesting false-positive intraoperative cholangiographic findings or natural passage of the stones. Iatrogenic complications, availability, and experience related to laparoscopic bile duct exploration and ERCP remain areas of concern in this management schema. Given these variables, most surgeons in our academic practice perform selective cholangiography when evidence suggestive of CBDS is low, attempt CBDS flushing and/or manipulation, and obtain postoperative ERCP when clinically significant stones persist. Anecdotally, these procedures have resulted in a low rate of complications, avoided the technical and logistic demands of laparoscopic bile duct exploration, and minimized the incidence of open incisions. The availability of pertinent equipment, specialists, and technical ability varies among institutions, and therefore management algorithms must be individualized until these variables are more uniform among all surgeons’ practices.

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