In the general population with cholelithiasis the incidence of CBD stones has been reported as 5%-15% whereas in those with SCA it ranges from 18% to 30%[7-10
]. Because of the high incidence of choledocholithiasis in patients with SCA, routine IC was advocated[7
]. With the recent advances in LC, exclusion of CBD stones is of great importance. This is specially so in patients with SCA who frequently present with CJ and are known to have a high incidence of cholelithiasis and choledocholithiasis. There are those who advocate routine laparoscopic IC to delineate the anatomy and to detect CBD stones[11-16
]. Lillemoe et al[17
] on the other hand advocate the selective use of laparoscopic cholangiography. Although laparoscopic IC is feasible, it has several disadvantages. It requires operators who are experienced in laparoscopic surgery, it is not technically easy, and it is known to increase the operative time. It also makes it difficult to decide, when CBD stones are diagnosed and difficult to retrieve, whether to convert the operation to open or wait and do a post-LC ERCP. Add to this a 20%-25% false positive rate of IC that may lead to unnecessary CBD exploration or conversion to open cholecystectomy[16
]. In a prospective study of CBD calculi in patients undergoing cholecystectomy, Nathanson et al[18
] found choledocholithiasis in 3.4%, and concluded that laparoscopic IC would result in unnecessary interventions in 50% of patients who had either false positive results or subsequently passed the stones. Another study in 343 patients who underwent LC concluded that routine IC should be discouraged in view of the low yield and significant rate of false positive results[19
]. However, Targarona et al[20
] stated that the choice of diagnostic and therapeutic strategies for CBD stones should depend on local circumstances and available expertise. We found ERCP to be valuable both for the diagnosis and management of CBD stones in patients with SCA who were scheduled to have LC, or in those who presented with retained CBD stones following LC. Our policy is that all SCA patients with cholelithiasis who have a dilated CBD on ultrasound, biochemical evidence of obstructive jaundice (elevated alkaline phosphatase, elevated total bilirubin of more than 50 mg/L), or a history of pancreatitis either alone or in combination, and those who have choledocholithiasis detected on ultrasound, should undergo ERCP to confirm and extract the stones, followed by LC. We, like others, support a policy of preoperative ERCP for those with risk factors for CBD stones followed by LC[21,22
]. However, magnetic resonance cholangiopancreatography and or endoscopic ultrasound, if available, should replace ERCP as a diagnostic method to detect CBD stones as this will reduce the number of negative ERCPs and avoid the risks and complications of ERCP particularly for those with dilated CBD without stones.
In conclusion, considering the high incidence of CBD stones in patients with SCA, it is important to exclude them as a cause of CJ whether pre- or post-cholecystectomy. This is specially so in the era of LC. Laparoscopic IC, although feasible, is not easy to perform, is time-consuming, requires expertise, and may necessitate conversion to open surgery if CDB stones are identified. We found ERCP valuable in this regard whether pre- or post-LC, and in none of our patients was there a need to perform laparoscopic IC. Sequential endoscopic sphincterotomy and stone extraction followed by LC is beneficial in these patients[23,24
]. Since we started using ERCP, none of our patients required CBD exploration and all CBD stones, whether diagnosed preoperatively or postoperatively, were managed by endoscopic sphincterotomy and stone extraction. Endoscopic sphincterotomy may also prove to be useful in these patients as it may prevent the future development of biliary sludge and bile duct stones.