Management of common bile duct stones: surgical versus gastroenterological perspectives

Gallstones related complications are one of the most common presentations to emergency surgical and medical take. Up to a fifth of adults in Europe have gallstones. One in 10 patients with symptomatic gallbladder stones have concomitant common bile duct (CBD) stones. CBD stones can be asymptomatic or can cause obstructive jaundice, cholangitis or pancreatitis. The initial investigations of CBD stones include ultrasound and liver function tests. Further imaging with magnetic resonance cholangiopancreatography or endoscopic ultrasound can be considered. The treatment options include single-stage cholecystectomy and CBD exploration or endoscopic retrograde cholangiopancreatography (ERCP). CBD exploration is performed under general anaesthetic (GA) and can be done via transcystic or transductal approach. It comes with the risks of bile leak, bile duct injury, bile duct stricture and retained stones. ERCP can be performed under conscious sedation, deep sedation or GA. The risks include pancreatitis, bleeding, perforation and cholangitis. The aim of this review article is to describe the relevant anatomy and physiology, outline the investigation pathway, classify CBD stones, describe and compare the treatment of CBD stones with CBD exploration and ERCP and describe the treatment of CBD stones in patients with altered anatomy.