Management of choledocholithiasis: Current opinions and personal experience

Background: The main therapeutic choices for choledocholithiasis are between endoscopic approach and laparoscopic approach. Usually the option for endoscopic or laparoscopic approach is largely connetted by the experience of the surgeons and endoscopists. The purpose of this study was to demonstrate the advantages, high success rate, contained morbidity, prevention of possible recurrent pancreatitis in our management experience. Material and Methods: in the period June 2000-June 2017 we have observed and treated 167 patients with choledocholithiasis without pancreatic involvement. In the same period we have treated 351 patients with acute pancreatitis; the majority of these cases was of biliary etiology. In all our patients the certain diagnosis of choledocholithiasis has been performed preoperatively with the usual diagnostic procedures, from the suspicious clinical data as biliary colic, laboratory data as increase of cholestasis indexes, instrumental data as CBD dilation, to direct detection of CBD stones by US or, more frequently, by MRCP or, in few cases with highest risk patients of choledocholithiasis, by ERC, employed simultaneously as diagnostic and therapeutic procedure. Results: ERC has been performed in 148 patients for therapeutic purpose of stones removal, at the same time of the diagnostic confirmation. The therapeutic success rate of ERC has been 89,18% (132 patients). All patients were submitted to laparoscopic cholecystectomy, waiting steady pancreatic conditions after ERC, usually after 5-7 days. We observed 9 cases (6,08%) of unbelical port-site infection treated with medical therapy and 3 umbelical hernias (2,02%). Complications post-ERC were: 1 duodenal perforation (0,6%), 3 severe acute pancreatitis, 2 hemorrhage, treated with medical approach. Conclusion: Our choice is sequential procedure ERCP/ES, CBD cleaning, LC. This choice is based on high frequency of small and moved stones and high success rates, very low morbidity of this procedure