الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
SUMMARY AND CONCLUSION
Cholelithiasis, one of the most common medical conditions
leading to surgical intervention, affects approximately 10% of the
adult population. CBDSs develops in about 8%-20% of patients
having gallbladder stones, but in about 5% of cases the
gallbladder is empty.
One of the main reasons of investigating a patient with
gallstones prior to cholecystectomy is to exclude the presence of
associated CBD stones. All investigations are aimed at evolving
a minimally invasive approach with the least number of
complications achieved in a cost effectiveness manner to
achieve a low overall morbidity of treatment. CBD stones are
suspected if there is a history of pancreatitis or cholangitis, or
there is increased serum levels of conjugated bilirubin, SGPT,
SGOT and alk. phosph., or if there is dilatation of CBD more
than 8mm or stone in the CBD at abdominal sonography or the
presence of stones in the CBD at MRCP.
The management of CBD stones traditionally required open
laparotomy and bile duct exploration. With the advent of
endoscopic and laparoscopic technology the main options for
treatment are pre- or postoperative ERCP with endoscopic biliary
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Summary & Conclusion
sphincterotomy (EST), laparoscopic trans-cystic exploration of
common bile duct and laparoscopic choledochotomy.
The treatment of common bile duct stones has shown
considerable evolution over the last 4 decades. The cause for
this evolution has been constant up gradation of technological
capability, which allows treating clinicians to offer cure.
ERCP has been the gold standard for preoperative diagnosis
of choledocholithiasis. It has the advantage of providing a
therapeutic option when a stone is identified. Successful
cholangiography by an experienced endoscopist is achieved in
greater than 90% of patients. Complications associated with
ERCP can be as high as 15% and include pancreatitis, cholangitis,
perforation of the duodenum or bile duct and bleeding. The
morality rate of ERCP is 0.2-0.5%
Laparoscopic CBD exploration may be done after initial
confirmation (detection) of a stone by IOC laparoscopic
ultrasound. The cystic duct is dilated with graded dilators,
balloon dilatation and Choledochoscopic stone removal is done.
The same limitations to transcystic intervention are applicable
in laparoscopy as well. Alternatively the CBD may be
approached by a choledo-chotomy where the CBD is opened
with scissors or a harmonic scalpel and the CBD explored using
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Summary & Conclusion
a therapeutic choledochoscope. Alternatively Steerable
catheters under fluoroscopic guidance are used. Laparoscopic
ante grade sphincterotomy may be added to provide bile duct
drainage and to prevent the problem of recurrence.
Various combinations of methods are available in the
management of choledocholithiasis and should be tailored
accordind to the patient’s criteria, surgical expertise, combined
with the availability of the specific technology needed for each
procedure.
There are many interventions techniques under trial as
lithotripsy and ESWL used in the treatment of difficult cases of
CBDS that can’t be managed with the usual methods.