Future Treatment of Common Bile Duct Stones.

Management options for patients found to have common bile duct stones have expanded as a function of improved instrumentation and radiographic support. Technological advances initially lead to increased costs but eventually result in improved quality for patients. Controversy exists for patients with either soft clinical findings or stones found at the time of laparoscopic cholecystectomy. As laparoscopic common duct exploration becomes more widespread the need for perioperative ERCP will likely decrease; however, this will depend on the experience of the surgeons at a given institution. Common bile duct stones found at the time of laparoscopic cholecystectomy can be approached in a variety of different ways. The most commonly used methods are laparoscopic transcystic common bile duct exploration, laparoscopic choledochotomy with common bile duct exploration, open common bile duct exploration, laparoscopic antegrade sphincterotomy, and postoperative ERCP. In the future, the treatment goal of biliary lithiasis will be to accomplish cholecystectomy and removal of bile duct stones in a single stage. Advances in fiberoptic technology will make transcystic duct exploration more effective, but it is likely that sphincterotomy (antegrade or retrograde) will be used preferentially for the distally impacted stone.