Cholelithiasis with choledocholithiasis is a common condition worldwide. Associated CBD stones are seen in 10-15% of patients with cholelithiasis. ERCP for the management of CBD stones followed by cholecystectomy is the most common modality of treatment. Presently it is a convenient, safe and cost-effective procedure with a success rate of 83.33%. Cholelithiais and Choledocholithiais have affected mankind since time immemorial. Archeological excavation more than 2000 years ago has demonstrated the presence of gall stones in gall bladder and CBD. The first cholecystectomy was performed in 1882 by Carl Langenbuch [1]. Gall bladder stones are more common in females and is a common health problem throughout the world. The clinical presentation of choledocholithiasis may vary widely, as CBD stones may be asymptomatic in 5-10% of cases [2]. Bernhard Riedel removed several choledochal stones and carried out a side-to-side anastomosis between the bile duct and duodenum in year 1888. This was the first choledochoduodenostomy (CD) [3,4]. Common bile duct produces colicky pain, jaundice or potentially life-threatening complications, such as ascending cholangitis or acute pancreatitis. The objective of this review article was to describe the socio epidemiological profile of the patients presented with cholelithiasis along with choledocholithiasis.

Cholelithiasis with choledocholithiasis is a disease of young and middle age. In a study done by Mohamed Mohsen Salem et al [5] in 2019 on 50 patients age ranged between 21 and 70 years with a mean age of 47.24 years and the ratio of M: F was 1: 4.56.

Management of GSD with Choledocholithiasis

In patients having concomitant gall stones with common bile duct stones, Cholecystectomy generally is recommended in patients after bile duct clearance to decrease the risk of future cholecystitis and recurrent biliary colic. As many as 24% of patients have been found to require cholecystectomy at follow-up after endoscopic papillotomy at an average of 14 months.

The obvious goal of therapy in choledocholithiasis is to achieve ductal clearance with the fewest number of interventions, lowest cost and least morbidity [5]. Stones in gall bladder and in Common Bile Duct can be dealt with various methods: 

• ERCP followed by Cholecystectomy (Laparoscopic or Open).

• Open cholecystectomy with choledocholithotomy with Primary closure of CBD or T-tube drainage.

• Open              cholecystectomy with choledocholithotomy  with choledochoduodo-nostomy

• Laparoscopic cholecystectomy with laparoscopic Common Bile Duct Exploration with Primary closure or T- tube drainage

The choice is often led by the availability of professional expertise and resources, rather than by superiority of one strategy over another. LC preceded by pre-operative ERCP remains the cornerstone and most commonly practiced strategy worldwide for management of co-existing gallbladder and CBD stones [6].

Because over 80% of gallbladders are removed laparoscopically, simultaneous laparoscopic common bile duct exploration is another option to treat CBD stones. It is a difficult procedure that requires a great deal of laparoscopic skill therefore it is done in fewer patients. The advantages are clear; the gallbladder and CBD stones are taken care of simultaneously in a minimally invasive manner that leads to shorter hospital stay and less pain than the corresponding open procedure or laparoscopic cholecystectomy/ERCP combination. Stones extraction may be performed by a trancystic or choledochotomy approach. Several techniques have been described for primary common bile duct closure (PCBDC) following choledochotomy. Closure over a T-tube is a technique with up to 15% complications, comparable figures to open surgery. A viable alternative to reduce complications from T-tube is the laparoscopic placement of an antegrade stent, followed by bile duct closure. However, this technique also presents a high rate of complications according to several series, including the development of acute postoperative pancreatitis (AP). Recently, primary bile duct closure during surgery following intraoperative cholangiography (IOC) has been proposed as a safe, reproducible technique with fewer complications than the previous procedures, where internal or external common bile duct drainage was performed.

Stanley et al [7], reported upper abdominal pain in 80% of the patients. Pain was present in 98 (90.74%) patients. This in comparison to a study done by Ehab El Hanafy et al [8], in which pain was the presenting feature in 90.5% of patients. Pain is a feature of cholelithiasis and choledocholithiasis and not in malignant causes of jaundice.  When stones in CBD obstruct the lumen then obstructive jaundice occurs. This jaundice regresses when obstruction is relieved. Detection of CBD stones by USG is low because distal CBD is not properly visualized on USG due to overlying gas filled loops of small bowel. Sensitivity of detection of gallstones by USG was 100%. And sensitivity of detection of CBD stones was 23% whereas the specificity was 92%.

Mark A Stott et al [9], did a study in which the sensitivity and specificity of USG for detection was 36% and 98% respectively. Gurusamy et al [10], concluded that many people may have CBD stones in spite of having a negative ultrasound or liver function test. Einstein DM et al [11], concluded that definite diagnosis of choledocholithiasis could be made on the basis of the sonograms in 22% of cases. Sensitivity and specificity of MRCP in detection of CBD stone was 100%. Hjartarson et al [12], supported that the use of MRCP as a tool for exclusion of choledocholithiasis as MRI has high sensitivity and specificity to diagnose choledocholithiasis. Grubnik et al [13], reported that a total of 256 patients with CBD stones were operated laparoscopically, bile duct stones were visualized pre-operatively by means of MRCP in all (100%) patients.

1. Morgenstern, L. "Carl Langenbuch and the First Cholecystectomy." Surgical Endoscopy, vol. 6, no. 3, 1992, pp. 113–14.

2. Sarli, L. et al. "Asymptomatic Bile Duct Stones: Selection Criteria for Intravenous Cholangiography and/or Endoscopic Retrograde Cholangiography Prior to Laparoscopic Cholecystectomy." European Journal of Gastroenterology & Hepatology, vol. 12, no. 11, 2000, pp. 1175–80.

3. Okamoto, H., K. Miura, J. Itakura, and H. Fujii. "Current Assessment of Choledochoduodenostomy: 130 Consecutive Series." The Annals of The Royal College of Surgeons of England, vol. 99, no. 7, 2017, pp. 545–49.

4. Salem, M., M. Esmat, A. Hassan, Y. Amer, H. Abdelaziz, and M. Rady. "Comparative Study Between Laparoscopic Common Bile Duct Exploration and Endoscopic Retrograde Cholangiopancreatography Plus Laparoscopic Cholecystectomy for Choledocholithiasis." International Surgery Journal, vol. 6, no. 7, 2019, p. 2250.

5. Jones, D. B., and N. J. Soper. "The Current Management of Common Bile Duct Stones." Advances in Surgery, vol. 29, 1996, pp. 271–89.

6. El Nakeeb et al. "Early Versus Late Cholecystectomy After Clearance of Common Bile Duct Stones by Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Study." Surgical Laparoscopy Endoscopy & Percutaneous Techniques, vol. 26, no. 3, 2016, pp. 202–07.

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8. El Hanafy, E., E. Atif, A. El Nakeeb, A. Abdel-Raouf, A. Shehta, and M. Abdel-Aziz. "Is Primary Closure a Feasible and Acceptable Option in the Era of T-Tube-Free Common Bile Duct Exploration for Choledocholithiasis?" The Egyptian Journal of Surgery, vol. 35, no. 3, 2016, p. 254.

9. Stott, M. A., P. A. Farrands, P. B. Guyer, K. C. Dewbury, J. J. Browning, and R. Sutton. "Ultrasound of the Common Bile Duct in Patients Undergoing Cholecystectomy." Journal of Clinical Ultrasound, vol. 19, no. 2, 1991, pp. 73–76.

10. Gurusamy, K. S., R. Koti, and B. R. Davidson. "T‐Tube Drainage Versus Primary Closure After Laparoscopic Common Bile Duct Exploration." Cochrane Database of Systematic Reviews, no. 6, 2013.

11. Einstein, D. M., S. A. Lapin, P. Ralls, and J. M. Halls. "The Insensitivity of Sonography in the Detection of Choledocholithiasis." American Journal of Roentgenology, vol. 142, no. 4, 1984, pp. 725–28.

12. Hjartarson, J. H., P. Hannesson, I. Sverrisson, S. Blöndal, B. Ívarsson, and E. S. Björnsson. "The Value of Magnetic Resonance Cholangiopancreatography for the Exclusion of Choledocholithiasis." Scandinavian Journal of Gastroenterology, vol. 51, no. 10, 2016, pp. 1249–56.

13. Grubnik, V., A. I. Tkachenko, V. V. Ilyashenko, and K. O. Vorotyntseva. "Laparoscopic Common Bile Duct Exploration Versus Open Surgery: Comparative Prospective Randomized Trial." Surgical Endoscopy, vol. 26, no. 8, 2012, pp. 2165–71.