Laparoscopic transcystic bile duct exploration: the treatment of first choice for common bile duct stones

This study was designed to explore the role of transcystic bile duct exploration (TCE) as a first line of treatment for patients with suspected or incidental common bile duct (CBD) stones. A prospective, case-control study of clinically comparable groups of patients who underwent laparoscopic cholecystectomy (LC) alone (n = 1,854) and combined LC/TCE for CBD stones (n = 253) under the care of one surgeon was performed. Other than ultrasonography, no routine preoperative imaging was used; however, we performed routine intraoperative cholangiography on all patients. There was no difference in age (49 +/- A 15 vs. 57 +/- A 19, p = 0.7), sex (79% vs. 82% females, p = 0.6), and ASA grade (1.9 +/- A 1 vs. 1.8 +/- A 1, p = 0.7). A larger proportion of the TCE group presented as an emergency (TCE 45% vs. LC alone 27%, p = 0.03) and more often presented with acute biliary pain compared with LC alone (27% vs. 13%, p = 0.02). Although a majority of the patients in the TCE group had clinical or biochemical risk factors for CBD stones (86%), only 27% had suspected stones on preoperative ultrasound. The incidence of jaundice (6% vs. 20%, p = 0.01) was lower in the LC alone group compared with TCE patients. Previous abdominal surgery was noted in 34% patients who underwent LC alone and 30% in LC/TCE (p = 0.06). Significantly there was no difference in open conversion between the two groups (LC alone 0.5% vs. LC/TCE 0.6%, p = 0.07). Comparison of selected outcome parameters for LC versus TCE showed a postoperative hospital stay of 2 (1-14) vs. 2 (1-17) days (p = 0.07), presentation to resolution 1 (1-11) vs. 1 (1-11) weeks (p = 0.07), and morbidity 1.07% vs. 1.2% (p = 0.07). The study advocates single-session laparoscopic cholecystectomy with transcystic CBD exploration as a feasible first choice treatment and the logical next step in the management of patients with CBD stones.