Educational disclaimer. This article is intended for clinician education and historical context. It is not a substitute for current society guidelines or individualized clinical judgement. Patients with suspected common bile duct (CBD) stones, acute cholangitis, or acute cholecystitis should be evaluated by a multidisciplinary team experienced in hepatobiliary endoscopy and surgery.
Introduction
Common bile duct (CBD) stones were first extracted via choledochotomy by Thornton in 1889. Choledochoduodenostomy (CDD) for biliary decompression was described by Riedel in 1888, and transduodenal sphincteroplasty (TDS) was developed in 1951 for the treatment of recurrent pancreatitis. Two innovations have since redefined this field. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST), introduced by Classen, Demling, and Kawai in 1974, displaced open CBD exploration as the dominant therapy for choledocholithiasis. Laparoscopic cholecystectomy, performed by Mouret in 1987 and popularised through the early 1990s, became the standard of care for symptomatic cholelithiasis (SAGES n.d.). Modern management of CBD stones is therefore framed around ERCP-based or laparoscopic strategies, with open common-duct exploration, CDD, and TDS reserved for highly selected cases.
Common duct exploration, CDD, and TDS in the management of ductal calculi are illustrated below by two historical case reports, each followed by a modern management note.
Case I
This sixty-four-year-old diabetic, hypertensive housewife gave a six-year history of intermittent pain in the right upper abdominal quadrant. The pain radiated to her back and was associated with vomiting. Nine days prior to admission her pain and vomiting recurred along with jaundice, pale stools, and dark urine. Cardiovascular review revealed palpitations, orthopnoea, exertional dyspnoea, and occasional pedal oedema. She was on insulin, oral antihypertensives, and anti-cardiac-failure therapy. On examination she was well hydrated, afebrile but icteric, with a pulse of 120/min, blood pressure 150/100 mmHg, and the cardiac apex displaced to the sixth left intercostal space. She was tender in the right upper quadrant and her stools were pale. She was assessed as having biliary colic with obstructive jaundice caused by stones in the common bile duct. Her investigations were:
| Test | Result | Unit | Test | Result | Unit |
|---|---|---|---|---|---|
| Hb | 14.2 | g/dL | WBC | 8 × 10⁹/L | |
| PT | 14.2 | sec (control 11.7 sec) | |||
| PTT | 36.7 | sec (control 29.7 sec) | |||
| Na | 140 | mmol/L | K | 4.3 | mmol/L |
| Cl | 101 | mmol/L | HCO3 | 23 | mmol/L |
| Urea | 13.6 | mmol/L | Creat | 110 | μmol/L |
| Glucose | 4.4 | mmol/L | Albumin | 31 | g/L |
| bili(T) | 154 | μmol/L | bili(D) | 78 | μmol/L |
| bili(I) | 76 | μmol/L | ALK PHOS | 141 | IU/L |
| SGOT | 172 | IU/L | GGT | 302 | IU/L |
| Amylase | 205 | IU/L |
Electrocardiogram and chest radiograph were normal; ultrasonography detected gallstones. The patient was given preoperative vitamin K and prophylactic amoxicillin and gentamicin. At laparotomy the gallbladder was inflamed, the CBD was dilated and contained palpable stones. Operative cholangiography showed two filling defects in the CBD. Open cholecystectomy was followed by common-duct exploration with retrieval of four stones, and biliary drainage was provided by CDD. She had an uneventful postoperative course and was discharged nine days after surgery.
Modern equivalent: Under the ASGE 2019 risk-stratification model this patient is high-risk for choledocholithiasis (CBD stones documented on imaging, biliary obstruction with bilirubin 154 µmol/L and a dilated CBD), and would proceed directly to ERCP without first obtaining MRCP or endoscopic ultrasound (EUS) (Buxbaum et al. 2019). ERCP with EST and balloon/basket stone extraction clears the CBD in 90–95% of cases at first attempt (Manes et al. 2019). Given her cardiac comorbidity, a two-stage approach — ERCP first, followed by interval laparoscopic cholecystectomy within two weeks — is the usual modern choice (Manes et al. 2019). A single-stage laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC + LCBDE) is an equally effective alternative in fit patients at experienced centres, with overall morbidity and mortality comparable to the two-stage ERCP-then-LC approach (Dasari et al. 2024). Choledochoduodenostomy is now rarely indicated.
Case II
Management of acute cholangitis with concomitant gangrenous cholecystitis
This forty-three-year-old hypertensive female presented with a six-month history of intermittent upper-abdominal pain and vomiting. Five days prior to admission her pains recurred. One day prior to admission she began vomiting and noted jaundice, dark urine, and pale stools, with chills and anorexia. She had previously undergone appendicectomy, left ovarian cystectomy, uterine myomectomy, and laparotomy with lysis of adhesions. Her hypertension was controlled by oral medication. On examination she was febrile (102 °F), dehydrated, and icteric, with a pulse of 100/min, blood pressure 150/90 mmHg, surgical abdominal scars, and a palpable tender gallbladder. Her stools were pale. Her investigations were:
| Test | Result | Unit | Test | Result | Unit |
|---|---|---|---|---|---|
| Hb | 8.9 | g/dL | WBC | 20.3 × 10⁹/L | |
| PT | 14.7 | sec (control 12.7 sec) | |||
| PTT | 47.7 | sec (control 32.2 sec) | |||
| Na | 143 | mmol/L | K | 3.9 | mmol/L |
| HCO3⁻ | 28 | mmol/L | Urea | 6.2 | mmol/L |
| Creat | 180 | μmol/L | Glucose | 9.5 | mmol/L |
| Albumin | 30 | g/L | bili(T) | 142 | μmol/L |
| bili(D) | 92 | μmol/L | bili(I) | 50 | μmol/L |
| ALK PHOS | 240 | IU/L | SGOT | 80 | IU/L |
| GGT | 594 | IU/L | Amylase | 380 | IU/L |
Chest and abdominal radiographs were normal; abdominal ultrasonography showed gallstones. The patient was rehydrated and given antibiotics. At laparotomy the inflamed gallbladder was gangrenous; inflamed tissues and adhesions obscured Calot’s triangle. A subtotal cholecystectomy was performed with recovery of numerous gallstones and placement of a cholecystostomy tube; operative cholangiography was not available. Postoperatively she became anicteric, but tube cholangiography detected an ampullary stone (Fig 1). Bile culture grew Citrobacter freundii and E. coli; urine grew E. coli. She was treated with appropriate antibiotics and her further course was uncomplicated. She was discharged two weeks after admission with her cholecystostomy tube in place. Six weeks later tube cholangiography showed persistence of the filling defect in the CBD. She underwent a second laparotomy under prophylactic antibiotics. Intraperitoneal adhesions were dense; an inadvertent perforation of the small bowel was repaired and the gallbladder remnant was excised. A transduodenal sphincteroplasty was performed and the stone retrieved. She was discharged eight days after sphincteroplasty and was well at six-week review.
Modern equivalent: Under the Tokyo Guidelines 2018, this presentation meets the diagnostic criteria for acute cholangitis (systemic inflammation, cholestasis, and imaging evidence) and is at least Grade II (moderate) (WBC > 12 × 10⁹/L, fever ≥ 39 °C, bilirubin ≥ 5 mg/dL [≈ 85 µmol/L]) (Kiriyama et al. 2018). She concurrently has acute Grade II gangrenous cholecystitis (Yokoe et al. 2018). Current management is IV antibiotics with urgent ERCP biliary drainage within 48–72 hours, accelerated to within 12 hours if organ dysfunction develops (Mukai et al. 2017). ERCP would address both the cholangitis and the impacted ampullary stone, with EST and stone extraction (large-balloon dilation if the stone is > 15 mm) replacing transduodenal sphincteroplasty (Manes et al. 2019). Once stable, the patient would undergo laparoscopic cholecystectomy; when Calot’s triangle is hostile, conversion to a planned subtotal cholecystectomy is the recommended bail-out per the SAGES Safe Cholecystectomy Program (SAGES 2020). Percutaneous cholecystostomy is reserved for unfit, non-operative candidates, with laparoscopic cholecystectomy preferred where feasible per the CHOCOLATE trial (Loozen et al. 2018).
Discussion
1. Incidence of CBD stones and complications
Approximately 10–20% of patients with symptomatic gallstones harbour CBD stones at the time of cholecystectomy, and a substantial minority go on to develop complications including biliary obstruction, cholangitis, and gallstone pancreatitis (Buxbaum et al. 2019; Williams et al. 2017). The ESGE 2019 guideline recommends that all patients with diagnosed CBD stones — symptomatic or not — undergo extraction if they can tolerate the procedure, because of the substantial risk of subsequent complications (Manes et al. 2019).
2. Diagnosis and risk stratification
The diagnostic approach has shifted from an ultrasound-PTC-ERCP triad to a structured risk-stratification model. The ASGE 2019 guideline classifies patients as (Buxbaum et al. 2019):
- High-risk — CBD stone visualised on abdominal imaging, or clinical ascending cholangitis, or total bilirubin > 4 mg/dL together with a dilated CBD (> 6 mm with gallbladder in situ; > 8 mm post-cholecystectomy). Recommendation: proceed directly to ERCP.
- Intermediate-risk — abnormal liver-function tests, age > 55, or a dilated CBD without the above criteria. Recommendation: confirm with MRCP or EUS before proceeding to ERCP. MRCP has a pooled sensitivity of approximately 85–93% and specificity 92–96%; EUS has a pooled sensitivity of 95–97% and specificity 87–97%, with the higher pickup for small distal stones (Buxbaum et al. 2019; Manes et al. 2019).
- Low-risk — none of the above. Recommendation: cholecystectomy with selective intraoperative cholangiography (IOC) or intraoperative ultrasound (IOUS).
Transabdominal ultrasonography remains first-line for confirming cholelithiasis and assessing CBD diameter, but its sensitivity for direct visualisation of CBD stones is only ~22–55%, so a normal study does not exclude choledocholithiasis (Buxbaum et al. 2019). Computed tomography is more useful for excluding alternative causes of biliary obstruction (e.g., malignancy) than for stone detection. Percutaneous transhepatic cholangiography (PTC) is no longer a routine diagnostic test; in modern practice it is a therapeutic option (drainage, antegrade stone extraction) when ERCP is impossible or has failed.
The ESGE 2019 guideline specifically recommends against routine antibiotic prophylaxis before ERCP for CBD stones. Antibiotics are reserved for established cholangitis or when complete biliary drainage cannot be assured (e.g., hilar obstruction, expected cholangioscopy-assisted lithotripsy) (Manes et al. 2019).
3. The anicteric patient with unsuspected CBD stones
Most CBD stones in patients with otherwise asymptomatic cholelithiasis are detected preoperatively by the ASGE risk-stratification workflow. Intraoperative cholangiography or laparoscopic intraoperative ultrasound is performed selectively in patients with intermediate or low pretest risk and is also valuable for delineating biliary anatomy to prevent bile-duct injury, an emphasis of the SAGES Safe Cholecystectomy Program (SAGES 2020). Routine IOC for every laparoscopic cholecystectomy is not supported by current evidence, but a low threshold for selective IOC is appropriate when bile-duct anatomy is unclear or unexpected findings arise (Buxbaum et al. 2019; SAGES 2020).
4. Management of diagnosed CBD stones
The modern algorithm offers two equivalent first-line strategies and a third reserved option.
ERCP with endoscopic sphincterotomy (EST) and stone extraction is first-line for most patients. Stones are extracted with balloon catheters or Dormia baskets under fluoroscopy. CBD clearance is achieved in 90–95% of patients at first session; with adjuncts (large-balloon dilation, mechanical lithotripsy, cholangioscopy-guided laser or electrohydraulic lithotripsy) overall clearance approaches 95–100% (Manes et al. 2019). The 30-day morbidity is approximately 5–10% — post-ERCP pancreatitis 3–5%, bleeding 1–2%, perforation 15 mm, intrahepatic, distal taper, or impacted), endoscopic papillary large-balloon dilation (EPLBD) with a 12–20 mm balloon following a limited sphincterotomy is now first-line and reduces the need for mechanical lithotripsy by 30–50% (Manes et al. 2019). Single-operator cholangioscopy with laser or electrohydraulic lithotripsy has high success rates for stones refractory to balloon/basket extraction or EPLBD (Bang et al. 2020). When a patient with the gallbladder in situ is treated by ERCP, laparoscopic cholecystectomy is recommended within two weeks to prevent recurrent biliary events (Manes et al. 2019).
Single-stage laparoscopic cholecystectomy with laparoscopic CBD exploration (LC + LCBDE) is an equally effective alternative when the appropriate expertise is available. The transcystic approach is preferred for small ( 12 or < 4 × 10⁹/L; fever ≥ 39 °C; age ≥ 75; bilirubin ≥ 5 mg/dL; albumin < 0.7 × lower limit of normal.
– Grade I (mild) — neither of the above.
Biliary drainage timing is graded to severity: Grade III within 12 hours, Grade II within 48–72 hours, and Grade I electively if antibiotics fail. ERCP with EST and stone extraction (or stent placement when stone clearance is unsafe in the acute phase) is the preferred first-line drainage modality. Percutaneous transhepatic biliary drainage (PTBD) and EUS-guided biliary drainage are second-line options for failed or anatomically inaccessible ERCP (Mukai et al. 2017). Empirical antibiotics should cover Gram-negative enteric organisms and anaerobes; coverage is narrowed once cultures (bile and blood) return.
6. Outcomes and comparators
Modern outcomes after definitive CBD-stone management compare favourably with open-surgical figures cited in historical references. Representative figures from current literature are summarised below.
| Procedure | CBD clearance | Overall morbidity | 30-day mortality |
|---|---|---|---|
| ERCP with EST (± EPLBD, ± lithotripsy) | 90–95% (first attempt); ~95–100% (with adjuncts) (Manes et al. 2019) | 5–10%; post-ERCP pancreatitis 3–5% (Loperfido et al. 1998) | ~0.9% (Loperfido et al. 1998) |
| Laparoscopic CBD exploration (LCBDE) | 80–95% (Dasari et al. 2024) | ~10–15% (Dasari et al. 2024) | < 1% (Dasari et al. 2024) |
| Open CBD exploration with T-tube (historical) | 85–95% | 15–25% (1980s open surgery) | 1–5% (1980s open surgery) |
Long-term recurrent-stone rates after ERCP/EST range from 4% to 24% depending on follow-up duration and patient factors (cholecystectomy status, periampullary diverticulum, sphincter dysfunction). Risk is reduced by complete stone clearance, treatment of biliary stasis, and timely cholecystectomy (Manes et al. 2019).
7. Nonoperative management of retained stones
Retained stones discovered on postoperative cholangiography are managed by ERCP with EST and stone extraction in nearly all cases. When a mature T-tube tract is present, basket extraction under fluoroscopic guidance via the tract remains an option ~5–6 weeks after surgery. Stones in the intrahepatic ducts or in patients with surgically altered anatomy (e.g., Roux-en-Y reconstruction) are increasingly addressed by single-operator cholangioscopy, laser/electrohydraulic lithotripsy, or EUS-guided rendezvous procedures (Bang et al. 2020; Manes et al. 2019).
Conclusion
The modern management of CBD stones is anchored in preoperative risk stratification, noninvasive imaging, and endoscopic or laparoscopic therapy:
- Stratify risk using the ASGE 2019 criteria; image intermediate-risk patients with MRCP or EUS.
- Use ERCP with EST and stone extraction as first-line therapy; add EPLBD or cholangioscopy-guided lithotripsy for difficult stones.
- Consider single-stage LC + LCBDE as an equally effective alternative in fit patients at experienced centres.
- After transcholedochal exploration with complete clearance, primary closure of the choledochotomy is preferred over routine T-tube drainage.
- In patients with the gallbladder in situ, perform laparoscopic cholecystectomy within two weeks after ERCP clearance to prevent recurrent biliary events.
- For acute cholangitis, apply the Tokyo Guidelines 2018 severity grading and timing of biliary drainage; ERCP is the preferred drainage route.
- Reserve open CBD exploration, choledochoduodenostomy, and transduodenal sphincteroplasty for highly selected cases or settings without endoscopic facilities.
References
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