Pavlidis Efstathios T, Pavlidis Theodoros E
2 Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece.
World J Gastrointest Surg. 2023 Feb 27;15(2):169-176. doi: 10.4240/wjgs.v15.i2.169.
The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.
胆囊结石合并胆总管结石的治疗策略基于一期或二期手术。其基本包括在同一手术中进行腹腔镜胆囊切除术(LC)联合腹腔镜胆总管探查术(LCBDE),或LC联合术前、术后甚至术中的内镜逆行胰胆管造影-内镜括约肌切开术(ERCP-ES)以清除结石。全球最常用的方法是术前进行ERCP-ES并取出结石,随后进行LC,最好在第二天进行。在术前ERCP-ES不可行的情况下,有人主张采用术中会师ERCP-ES并同时进行LC的替代方法。术中取出胆总管结石优于术后会师ERCP-ES。然而,关于腹腔镜内镜会师的优越性尚无共识。这等同于传统的二期手术。内镜乳头大球囊扩张可降低复发率。LCBDE和术中ERCP有相似的良好效果。ERCP-ES后的复发风险大于LCBDE后的复发风险。腹腔镜超声检查可明确解剖结构并检测胆总管结石。大多数外科医生在进行胆总管探查时,无论有无T管引流,更倾向于经胆管途径而非经胆囊途径,但应尽可能采用经胆囊途径。由经验丰富的外科医生进行LCBDE是一种安全有效的选择。然而,需要特定设备和高级培训是其缺点。当ERCP失败时,经皮途径是一种替代方法。可能需要对残留结石进行手术或内镜再干预。对于无症状的胆总管结石,ERCP取石是首选方法。一期和二期治疗均可接受,且都能确保生活质量得到改善。
World J Gastrointest Surg. 2023-2-27
Cochrane Database Syst Rev. 2013-12-12
Cochrane Database Syst Rev. 2013-9-3
J Gastrointest Surg. 2008-11
J Laparoendosc Adv Surg Tech A. 2023-1
World J Gastrointest Surg. 2025-7-27
World J Gastrointest Surg. 2025-3-27
Diseases. 2024-8-26
J Surg Case Rep. 2024-9-18
World J Gastrointest Surg. 2022-8-27
J Gastrointest Surg. 2023-3
Adv Surg. 2022-9
Eur J Trauma Emerg Surg. 2023-10
Surg Laparosc Endosc Percutan Tech. 2022-10-1
Ann R Coll Surg Engl. 2023-9