Symptomatic cholelithiasis merits laparoscopic cholecystectomy. Nearly 10-15% of patients waiting for laparoscopic cholecystectomy could harbor simultaneous bile duct stones [1,2]. Bile duct stones should be tackled swiftly in order to prevent potential life-threatening complications like cholangitis, biliary pancreatitis and obstructive jaundice. Clear guidelines are lacking for management of gall stones with concomitant bile duct stones. Various options are available namely open surgery, endoscopic intervention and laparoscopic approach. We aim to formulate practical guidelines for management of such cases after carefully considering the available current evidence, local resources and surgical expertise.

Patient with gall bladder stones could present with biliary colic or with complications like acute cholecysttis, Mucocele of GB and Empyema of GB. 10-15% % of such patients could also have common bile duct stones. Bile duct stones could be asymptomatic or can present with intermittnet jaunce, fever and pain (Charcot’s triad). Past history of jaundice, pancratitis should also alert us to the possibility of bile duct stone [3,4].

Though raised direct bilirubin, raised alkaline phosphaste and marginally raised transaminases are often noted in cases of bile duct stones, there are occasions when liver function test could be totally normal [1-4].

Transabdominal ultrasound is usually very sensitive and specific to pick up gall stones. But abdominal ultrasound has only about 60% sensitivity in picking up bile duct stones. Dilated bile duct (more than 6 mm) could be the lone indirect indicator of distal CBD stone and hence one should be watchful.

Spiral CT abdomen is ideally suited to evaluate jaundiced patient with mass lesions.

MRCP (magnetic resonance cholangiopancreatography) is the MRI of biliary and pancreatic tree and it is very sensitive and specific to pick up bile duct stones up to 5mm in size. MRCP is considered as the investigation of choice nowadays to evaluate cases with combined gall stones with bile duct stones.

Endoscopic ultrasound is an invasive diagnostic modality with high specificity and sensitivity that is much better than MRCP. But it is highly operator dependent and available only in few centers hence EUS is seldom useful for routine practice.

ERCP (endoscopic retrograde cholangiopancreatography) is the treatment of choice for bile duct stones. Its benefits are obvious if we compare it with open and laparoscopic bile duct exploration. But one has to keep in mind the potential complications of ERCP like post ERCP pancreatitis, bleeding and perforation if not performed well.

Options for management of gallstones with concomitant bile duct stones

• Two session procedures:
  • ERCP followed byLap cholecystectomy
  • Urgent Pre-operative ERCP
  • Elective Pre-operative ERCP
  • Lap cholecystectomy followed by post op ERCP
• Single session procedures:
  • Lap cholecystectomy with intra operative ERCP
  • Laparoscopic exploration of CBD
  • Trans cystic exploration
  • Transductal exploration

Role for Urgent Preoperative ERCP

Following situations warrant urgent pre-operative biliary decompression by ERCP prior to tackling gall stones 8.

1. Patient with acute cholangitis who fails to respond to antibiotic

therapy or who has signs of septic shock would require urgent biliary decompression. Endoscopic CBD stone extraction and/or biliary

stenting is recommended in this setting

2. Patient with pancreatitis of suspected or proven biliary origin

who has associated cholangitis or persistent biliary obstruction is recommended to undergo biliary sphincterotomy and endoscopic Stone extraction within 72 hours of presentation?

Role for elective pre-operative ERCP

(Sequential therapy or Twin session therapy)

In patient with combined gall stone and bile duct stones, the conventional treatment is elective pre-operative ERCP to clear the bile duct followed by lap cholecystectomy after few days. This method of sequential therapy entails prolonged hospital stay, 2 separate procedures by 2 different teams with associated expenses. Hence following method of single session procedure of laparoscopic cholecystectomy and intra operative ERCP has received the attention of surgical fraternity

Philosophy of Single Stage ERCP with Lap cholecystectomy [5-10]

(Simultaneous therapy, Single session therapy or Laparo-endoscopic rendezvous technique)

In patient with combined bile duct stones and gall stones, we can make a case for single session ERCP and lap cholecystectomy with obvious benefits,

Provided the following favorable findings are present

• Patient is stable and no evidence of significant sepsis
• Mild (Bilirubin < 5) or no jaundice
• CBD showed one or few small stones (<10mm) and no proximal stricture or abnormal anatomy
• Patient has no history of previous upper GI surgery
• Availability of expertise for single stage ERCP and Lap cholecystectomy

Type 1 Single session therapy: (ERCP followed by Lap cholecystectomy)

Patient is given GA. Do ERCP to confirm bile duct stones followed by Sphincterotomy and balloon sweep or Dormia basketing to remove all the stones. Perform balloon occlusion cholangiogram to confirm clearance of bile duct and place 7F biliary plastic stent. Insert nasogastric tube to deflate the gut that is followed by 4 ports conventional laparoscopic cholecystectomy and subhepatic drain placement.

Proponents for this approach prefer because of following reasons

• Bile duct stones are cleared prior to lap cholecystectomy
• If any difficulty with ERCP or inability to remove stone after ERCP, one could plan for either laparoscopic or open CBD exploration in the subsequent session

Type 2 Single session therapy: (Lap cholecystectomy followed by ERCP)

Patient is given GA. Perform 4 port lap cholecystectomy. Intra operative cholangiogram is done if patient had no recent MRCP to confirm the size of bile duct and size, site and number of bile duct stones. Following the extraction of GB, we routinely place a subhepatic drain in patients undergoing ERCP. Then we perform ERCP in the supine position (our preferred method) to confirm size and number of stones and exclude bile duct injury or any cystic stump leakage following cholecystectomy. Some centers prefer insertion of hydrophilic guidewire through cystic duct during laparoscopic procedure to enable the endoscopist to perform sphincterotomy with relative ease. Bile duct stones are usually removed by using biliary Fogarty balloon or Dormia basket. In selected cases of larger bile duct stones (10-15mm), one could consider CRE balloon sphincteroplasty to aid easy removal of stone or else one may have to consider mechanical lithotripsy. Following clearance of bile duct, a double pigtail plastic stent is placed which can be removed after 2-3 weeks.

We have reviewed our results during year 2015-18. Total of 79 patients had undergone treatment for gall stones with concomitant bile duct stones (Two session procedure in 41 patients and single session procedure in 38 patients). Results were comparable in both groups with shorter hospital stay in single session group (5.3 Vs 3.8 days)

We prefer this approach because of following reasons

• Lap cholecystectomy is relatively easy before ERCP. Gaseous distension of bowels makes post ERCP cholecystectomy technically demanding.
• ERCP following Lap cholecystectomy helps to assess for secure cystic duct clipping and for any bile duct injury or leakage

A case for Lap cholecystectomy with LCBDE [14-18]

It is recommended that, in patients undergoing laparoscopic cholecystectomy, trans cystic or transductal laparoscopic bile duct exploration (LBDE) is an appropriate technique for common bile duct stone removal. There is no evidence of difference in efficacy, mortality or morbidity when LCBDE is compared with perioperative ERCP. It is recommended that the two approaches are considered equally valid treatment options.

In experienced hands, laparoscopic CBD exploration has a success rate of over 90 percent. There are two different types of CBD exploration namely trans cystic and transductal exploration.

When a decision has been made to perform CBD exploration,

Intraoperative cholangiography should be performed to confirm the diagnosis and outline the biliary anatomy before the formal exploration is undertaken

Contrast is then injected under continuous fluoroscopic visualization with 1:1 dilution of water-soluble contrast and water. The images should be evaluated for the length of the cystic duct and the junction with the CBD, the size of the CBD, free flow of contrast into the duodenum, the intra and extrahepatic biliary anatomy, and the presence of filling defects.

The following findings on cholangiography namely dilated bile ducts, filling defects, or failure of contrast flow into the duodenum suggest possible presence of bile duct stones.

Consider following factors to choose the appropriate type of CBD exploration

• Patient factor
  • Age
  • Co morbid illness
  • Fitness for GA
  • No, size & location of stones
  • Size of bile duct
  • Size and course of cystic duct
• Surgeon factor
  • Expertise and Resource
  • Cost, effectiveness & morbidity of the procedure