Postoperative ERCP Versus Laparoscopic Choledochotomy for Clearance of Selected Bile Duct Calculi: A Randomized Trial

The ideal management of bile duct (BD) stones in the era of laparoscopic cholecystectomy remains controversial. Options range from endoscopic retrograde cholangiography (ERCP) in all or selected patients, through to clearance of theBD through the cyctic duct or via laparoscopic choledochotomy. Clinical management of BD stones in the last decade has focused on precholecystectomy detection with ERCP clearance in those with suspected stones.2,3,11,14 This clinical algorithm successfully clears the stones in most patients, but no stones are found in 20% to 60% of patients, and rare unpredictable severe morbidity can result in this group. Increasing efforts to reduce the number of nontherapeutic ERCPs using MRCP3 and endoscopic ultrasound11 are being undertaken. Our initial experience of 300 consecutive patients with fluoroscopic cholangiography and intraoperative clearance demonstrated that, for the pattern of stone disease we see, 66% of patients’ BD stones can be cleared via the cystic duct with dramatic reduction in morbidity compared with the 33% requiring choledochotomy or ERCP.23 Furthermore, increased accuracy of detecting BD stones prior to cholecystectomy has not yet been able to predict which stones will be able to be extracted via the cystic duct and which patients would require choledochotomy or ERCP. Given the limitations of the preoperative approach to BD stone clearance, this trial was designed to explore the limitations of the alternative approach where, for patients failing laparoscopic transcystic BD stone clearance during cholecystectomy, we compared the outcomes of BD stone clearance by laparoscopic choledochotomy or postoperative ERCP.