Choledocholithiasis--therapeutic splitting
Boeckl, O.; Sungler, P.; Heinerman, P.M.; Lexer, G.
Der Chirurg; Zeitschrift für Alle Gebiete der Operativen Medizen 65(5): 424-429
1994
ISSN/ISBN: 0009-4722 PMID: 8050295 Document Number: 437687
Despite new developments like chemolitholysis and extracorporeal shock wave lithotripsy, conventional cholecystectomy was the "gold standard" in the treatment of gallstones. The range of indications and the operative strategy were well standardized, although the management of common bile duct stones in gallstone disease was still under debate. For high-risk and elder patients endoscopic retrograde cholangio-pancreatography (ERCP), papillotomy and stone extraction was established, in younger patients the best management was questionable. According to better and more accurate preoperative tests like ultrasound and the ample evidence of the function of the papilla after endoscopic papillotomy the trend seemed to be the preoperative endoscopic bile duct clearance in all patients, just when the "bushfire" of laparoscopic cholecystectomy arised and until then praised standards were thrown overboard because of technical difficulties. Routine intraoperative cholangiography (IOC) was replaced by indicated selective IOC due to the lack of talent of many surgeons. Only the therapeutic concept of the removal of the stone-bearing gallbladder survived all new concepts and the debate of wether to perform routine IOC and wether to clear the bile ducts - pre-, intra- or postoperatively or primarily or secondarily convert to open cholecystectomy and bile duct revision. In the eye of a new "gold standard" and according to the literature and our own results we should standardize our management especially in the era of laparoscopic cholecystectomy as "therapeutical splitting" with indicated and selective preoperative ERCP and bile duct clearance offers the best results and facilitates minimally invasive surgery.