【正文】 ctomy ? 12% cholecystectomies ? 90% have preoperative indications (jaundice, pancreatitis or abnormal LFTs) ? 5%10% have no preop indication and are detected at IOC (filling defect, absence of filling terminal segment of CBD or delay/absence of flow into duodenum) The best management of CBD stones is still a matter of debate ERCP General agreement ERCP is preferable in ? Postcholecystectomy patients ? High risk surgical patients who still have a gallbladder ? Severe acute cholangitis ? Selected patients with acute biliary pancreatitis ? Failed transcystic exploration with a CBD 8mm ERCP Areas of disagreement ? First line management of CBD stones ? Preoperative CBD clearance ERCP ? CBD clearance 90%95% with successful sphincterotomy (papillary dilatation is an alternative) ? Overall clearance 80%95% (improves with experience of endoscopist) ? Major plications in 10% ERCP plications Acute (5%) ? Haemorrhage 1%6% ? Acute pancreatitis 1%19% ? Cholangitis ? Retroduodenal perforation 1%2% ? Failure to clear or access duct 2%18% Overall procedure mortality 1% 30 day mortality can reach 15% (reflects severity of underlying disease) ERCP plications Medium ? Recurrent stones 2%14% ? Cholangitis 1%6% ? Bacterobilia 60% Late ? Bile duct malignancy 2% (Prat et al, Gastroenterology, 1996 amp。 Tanaka et al, Gastrointest Endosc, 1998) Difficult bile duct stones at ERCP ? Stones 15mm ? Intrahepatic stones ? Multiple stones ? Impacted stones ? Stone proximal to biliary stricture ? Tortuous bile duct ? Disproportionate size of bile duct stone ? Duodenal diverticulum ? Bilroth 2 reconstruction ? Surgical duodenotomy Adjuvant techniques ? Mechanical lithotripsy ? Extracorporeal shockwave lithotripsy ? Chemical dissolution ? Successful stone fragmentation has been reported in up to 80% of patients, but major drawback is the need for multiple treatment sessions and repeat ERCP to retrieve stone fragments ERCP stent insertion ? 5% of cases where stone extraction fails either a nasobiliary tube or stent should be inserted for CBD depression ? Stents may block after a few months, but bile often drains around stent ? If surgically unfit can change stents if jaundice recurs ? Recurrent episodes of cholangitis can lead to secondary biliary cirrhosis in the long term so careful consideration before surgery is totally discounted Preoperative ERCP ? Eliminates the intraoperative dilemma as to how to manage CBD stones ? Exposes a number of patients to an unnecessary procedure and associated plications ? Successful cannulation of papilla % with stones cleared in 86%, 13% unnecessary ERCP with failure rate % and morbidity % (Hamy, Surg , Endosc, 2022) ? Randomised study has shown no significant advantage for patient treated with preoperative ERCP with sphincterotomy vs open cholecystectomy and CBD exploration (Neoptolemos et al, Br J Surg, 1987) Preoperative ERCP ? Cholecystectomy should routinely follow clearance of CBD except in those too frail for a general anaesthetic ? If the gallbladder is left intact it can be expected that 47% of patients will develop at least on recurrent biliary event (Boerma et al, Lancet, 2022) Intraoperative ERCP ? Described in literature but few centers consider it an appropriate use of resources Postoperative ERCP ? Dictated by local expertise and practice ? Small (5mm) stones found at IOC could be left to pass, follow up to 33 months found 29% developed symptoms and were subsequently managed successfully with ERCP (Ammori et al, Surg Endosc , 2022) Laparoscopic transcystic CBD exploration ? Fibreoptic instruments or radiologically guided wire baskets or balloons ? Two randomised trials have shown 60%70% of patients are able to have their calculi cleared via the cystic duct (Cuscherieri et al, Surg Endoscopy 1999 amp。 Rhodes et al, Lancet 1998) ? 12% patients managed without cholangiogram will present with a retained stone Transcystic exploration ? Standard dissection to identify cystic duct ? Cystic duct opened distal to a previously applied clip ? Milk stones from cystic duct ? Cholangiogram ? Assessment of stone and duct size ? Tiny stones or possible sphincter of oddi spasm try glucagon and flush with saline then repeat cholangiogram Transcystic exploration ? Nathanson basket fed into CBD (ensure tip of basket well back from tip to avoid duct perforation) ? Under image intensification tip positioned, basket opened and stone removed ? If stone impacted can dislodge with 4Fr fogarty catheter or perform choledochoscopy Techniques to improve transcystic clearance ? Careful dissection of cystic duct/CBD junction ? Avoidance of spiral valves when entering cystic duct ? Careful examination of cholangiogram ? Approach cystic duct from different or extra ports ? Dilation of cystic duct with a balloon ? Choledochoscopy via cystic duct ? Vary retraction on fundus ? Cystic duct closure clips or endoloops ? Subhepatic drainage Trans cystic exploration success ? Stones few in number ? Small in size (1cm) ? Situated in the mon duct or distal to the cystic duct entry Choledochotomy preferable if ? Large and/or numerous stones ? Common hepatic duct or intrahepatic ducts ? Careful consideration of laparoscopic strategies to be employed, equipment required and adequacy of assistance Indications for choledochotomy ? Unsuccessful transcystic exploration ? Cystic duct diameter smaller than stones ? CBD 8mm ? Multiple large stones ? Impacted stones with features of cholangitis ? Ampullary diverticulum on IOC ? Previous bilroth 2 gastrectomy ? Previous failed ERCP ? Contrai