In the CBD stone group, one patient (1/50, 2%) has been converted from laparoscopy to laparotomy because of adhesions and a stomach sero-muscular lesion. In addition, another patient underwent a laparotomy first due to a patent foramen ovale. In the No CBD stone group, 7 patients had a conversion (7/349, 2%), due to adhesions, severe pediculitis, haemorrhage, small bowel perforation, lack of identification of the cystic duct and necrotized gallbladder with peritonitis. In addition, two other patients underwent a laparotomy first due to severe heart failure and septic shock.
Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration.
In the CBD stone group (N = 50), all patients were assessed by IOC. In the No CBD stone group (N = 349), the IOC success rate was 81.4% (284/349). In the 65 patients without IOC, the absence of CBD stone was confirmed by MRCP, EUS, ERCP and by following the LFTs until their normalization, and checking the absence of subsequent management for a CBD stone.
Predictors of a CBD stone on IOC
During the study period, 612 adult patients were admitted for an acute gallstone-related disease and underwent a cholecystectomy. Among them, 399 patients were included in the study, and 213 were excluded because they underwent a pre-operative CBD assessment. Most of the patients were female (56.1%), with a mean age of 56 ± 19 years and a mean BMI of 28 ± 6 kg/m 2 (Table 1). Only two other patients were admitted during the study period, and were not included because they underwent a delayed cholecystectomy in subsequent hospital stay.
The risk of a CBD stone is classically defined by a combination of clinical, biological and radiological parameters . The present study assessed patients without previous CBD exploration and confirmed the value of LFTs, and clinical variables such as fever, as well as signs of cholecystitis on US . In addition, women were more likely to present a stone.
Patients could be categorized into three groups according to their risk of presenting a CBD stone following the ASGE/SAGE guidelines . Low-risk patients demonstrated normal LFTs. High-risk patients included those with serum bilirubin ≥ 70 μmol/l, a visible stone on pre-op imaging (ultrasound (US) or computed tomography (CT)), an ascending cholangitis, and those with bilirubin 30–70 μmol/l and CBD diameter >6 mm. Patients at intermediate risk of a CBD stone included those with abnormal LFTs not fulfilling the aforementioned criteria for high risk of a CBD stone. Based on a recent randomized clinical trial, patients at low and intermediate risk of a CBD stone were managed by cholecystectomy first  and represented the target population of patients included in the present study. High-risk patients underwent primary CBD endoscopic exploration followed by cholecystectomy and were not included in the present analysis to improve the population homogeneity.
The present study is limited by its retrospective nature and its potential for type 2 errors. However, it provides a real-life assessment of the proposed management strategy of patients at risk of CBD stones.
Studied variables included demographic data (age, gender, body mass index (BMI)), admission data (fever, right upper quadrant pain, signs of cholecystitis on US, admission LFTs), and outcome data (length of hospital stay, conversion rate to a laparotomy, complications according to the Dindo/Clavien classification ). In addition, we recorded post-operative LFTs in the patients with an image of a CBD stone on the IOC.
At repeat ERCP the pigtail stent was removed and the cholangiogram shows no evidence of calculi with satisfactory drainage from the common bile duct.
These are summarised in fig 1. Endoscopic extraction of common bile duct stones after spincterotomy and mechanical lithotripsy has a success rate of up to 95% and is considered the treatment of choice. 1, 2 The reason for failure in this case was the large size of the bile duct calculus. Other reasons include bile duct strictures, unusual anatomy, and calculi beyond reach of the wire basket. 1– 3
The patient then underwent one session of high energy ESWL, during which the calculus was targeted by ultrasonography. 1, 2 Studies have shown that between 20% and 50% of patients will require more than one treatment session. 3, 6, 7 The success rate of this procedure, with complete clearance of the common bile duct is between 80% and 90%. 1– 3, 6
Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?
In this case, given the patient’s age and comorbidities it was decided that this was the treatment of choice. Biliary drainage was achieved during initial ERCP using a pigtail stent.
Spontaneous passage of calculi occurs in up to 10% of patients, with 80% requiring removal of stone fragments during repeat ERCP. 1 Although recurrence of bile duct calculi is estimated at 14% after one year, most of these are amenable to endoscopic treatment. 2
Traditionally such patients have been referred for surgical exploration of the common bile duct but this procedure is not without risk, particularly in elderly patients or those with major medical comorbidities. 4
ESWL is an effective non-invasive treatment modality that can be performed safely on an outpatient basis, without use of general anaesthesia. For this reason it is a useful treatment option in patients with difficult common bile duct calculi who are considered to be poor candidates for surgery.
Extracorporeal shock wave lithotripsy (ESWL) was investigated initially for treatment of gallbladder stones, but a high stone recurrence rate has limited its use in this condition. 5 In recent years high energy ESWL has been used with more promising results in high risk patients with common bile duct stones.