Smith Shannon M, Kelley Jesse K, Zambito Giuseppe M, Banks-Venegoni Amy L
Department of Surgery, Corewell Health-Michigan State University, Grand Rapids, MI, USA.
Am Surg. 2025 Aug;91(8):1362-1367. doi: 10.1177/00031348251341960. Epub 2025 May 9.
The prevalence of cholelithiasis is estimated to be upwards of 30% within the United States population. Of these patients, 10-20% will progress to develop choledocholithiasis. Prior to 2000, choledocholithiasis was managed via open cholecystectomy and common bile duct exploration. However, as minimally invasive surgical techniques and endoscopy have advanced, the current management of choledocholithiasis has progressed to a two-staged, laproendoscopic approach consisting of endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Review of the literature from 2005 to 2025 reveals that the preferred approach to choledocholithiasis continues to evolve. Management of choledocholithiasis via a single-stage such as performing intraoperative ERCP at the time of laparoscopic cholecystectomy is associated with a statistically significant decrease in overall 30-day morbidity as well as shorter hospital length of stay compared with a twostaged laproendoscopic approach. Alternatively, performing intraoperative rendezvous endoscopy significantly improves patient morbidity profiles due the absence of post-endoscopic pancreatitis compared with ERCP. A third management option includes laparoscopic common bile duct exploration via a transcystic or transductal approach. These approaches are associated with superior stone clearance rates compared with ERCP as well as decreased cost and hospital length of stay. Barriers to implementation of these techniques include surgeon training, equipment availability, and appropriate staffing. Future studies should investigate the role of robotic surgery in the management of choledocholithiasis as well as compare patient centered outcomes between the three, single-staged approaches.
据估计，美国人群中胆结石的患病率高达30%以上。在这些患者中，10%-20%会进展为胆总管结石。2000年以前，胆总管结石通过开腹胆囊切除术和胆总管探查术进行治疗。然而，随着微创外科技术和内窥镜检查的发展，目前胆总管结石的治疗已进展为一种两阶段的腹腔镜内镜联合方法，即先进行内镜逆行胰胆管造影（ERCP），然后进行腹腔镜胆囊切除术。对2005年至2025年的文献回顾显示，胆总管结石的首选治疗方法仍在不断演变。与两阶段的腹腔镜内镜联合方法相比，通过单阶段方法（如在腹腔镜胆囊切除术时进行术中ERCP）治疗胆总管结石，在统计学上可显著降低30天总体发病率，并缩短住院时间。另外，与ERCP相比，进行术中会师内镜检查可显著改善患者的发病情况，因为不会发生内镜后胰腺炎。第三种治疗选择包括通过经胆囊或经胆管途径进行腹腔镜胆总管探查。与ERCP相比，这些方法的结石清除率更高，成本更低，住院时间更短。实施这些技术的障碍包括外科医生培训、设备可用性和适当的人员配备。未来的研究应调查机器人手术在胆总管结石治疗中的作用，并比较这三种单阶段方法以患者为中心的结局。
