Recurrent CBD stones: Evolution from open to laparoscopic surgery

Therapeutic policy and results of 25 years' experience in the management of CBD stones have been analyzed. The whole experience has been divided into three periods: open surgery of CBD stones (1969-1983), 636 cases of CBD lithiasis; endoscopic management of CBD stones (1984-1990), 149 cases of CBD lithiasis; era of laparoscopic cholecystectomy (1991-1994), 501 laparoscopic cholecystectomies with 37 cases of CBD stones (7.4%). The main peculiar issues characterizing the three periods are represented by the following points: a) progressive drop of percentage of CBD lithiasis (from 14.6% to 7.4%) as a consequence of under-utilization of diagnostic means (i.v. cholangiography, ERCP, intraoperative cholangiography) and, also, as a consequence of a total confidence in postoperative endoscopic management of recurrent CBD stones (85-90%); b) increased percentage of deliberately abandoned CBD stones when an endoscopic management is available (from 5.2% to 8.7%). For the same reason we have recorded a decrease of 'tactical' bilio-enteric anastomoses and sphincterotomies (from 9.5% to 2.7%). The well documented early morbility (2%) but mainly the late complications of endoscopic sphincterotomies suggest a great caution to avoid abusive indications in young patients. In our opinion the endoscopic approach is indicated in case of infected obstruction, in critically ill patients with biliary severe acute pancreatitis and in case of high surgical risk.