Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease
© The Author(s). 2017
Received: 6 December 2016
Accepted: 31 March 2017
Published: 17 April 2017
Recent data have suggested that upfront cholecystectomy should be performed even in the presence of moderately abnormal liver function tests (LFTs). As a consequence, more common bile duct (CBD) stones are discovered on intra-operative cholangiogram. We assessed the presentation and management of such patients to refine their management plan.
Adult patients (>16 years) with an acute gallstone-related disease who had undergone same-stay cholecystectomy from January 2013 to January 2015 were retrospectively assessed. We excluded patients with pre-operative endoscopic CBD exploration.
Among the 612 patients with same-stay cholecystectomy, 399 patients were included in the study, and 213 were excluded because of a pre-operative CBD exploration. Fifty patients (12.5%) presented an image of CBD stone on the intra-operative cholangiogram. Such patients were younger (47 vs. 55 years, P = .01) and less likely to present with fever (1 vs. 11.7%, P = .04) or signs of cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Admission LFTs were higher in patients with an image of a stone. Among the 50 patients with an image on cholangiogram, a stone was confirmed in 26 (52%). Most patients (n = 32) underwent post-operative assessment with endoscopic ultrasound (EUS). LFTs did not predict the presence of a confirmed stone. However, the absence of contrast passage into the duodenum was negatively associated with a confirmed stone (P = .08), and a filling defect was positively associated with one (P = .11). Most confirmed stones were successfully extracted by endoscopic retrograde cholangiopancreatogram (ERCP) (25/26, 96%), except in one patient who needed a per-cutaneous approach because of duodenal diverticuli.
Same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone is confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).
KeywordsSuspected common bile duct stone Same-stay cholecystectomy for acute gallstone-related disease Filling defect on intra-operative cholangiogram Trans-cystic drain
Gallstones are common and affect 10–15% of the adult population. Some 4% of these patients become symptomatic each year, with biliary colics, cholecystitis or cholangitis [1, 2]. In addition, 10–15% of the patients with symptoms also present a common bile duct (CBD) stone .
The likelihood of an associated CBD stone and its management have been established by the American Society for Gastrointestinal Endoscopy (ASGE) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines . Globally, patients with normal liver function tests (LFTs) are at low risk (<5%) for a CBD stone and should undergo cholecystectomy first. Those with elevated liver function tests (LFTs) are at increased risk, especially those with total bilirubin >70 μmol/l, which carries a risk for a CBD stone >50%. They should undergo a preliminary exploration of the CBD prior to cholecystectomy. We recently demonstrated that intermediate-risk patients with moderately elevated LFTs (including bilirubin <70 μmol/l) are best treated by upfront same-stay cholecystectomy with intra-operative cholangiogram . This strategy is associated with a decreased length of stay and the need for fewer CBD investigations compared with a primary CBD exploration followed by cholecystectomy. The net effect is that more patients are discovered with an intra-operative CBD stone during same-stay cholecystectomy, and a routine intra-operative cholangiogram is needed [4, 5].
The factors predicting the presence of a CBD stone could still be improved. Such factors could be applied prior to or during surgery. However, a perfect split between patients with and without stone will likely never occur due to the heterogeneity of the signs linked to a CBD stone and because some patients present interval migrations (prior to or during cholecystectomy). Finally, many patients show a spontaneous migration to the duodenum ; therefore, a cholangiogram image of a stone does not necessarily translate into a stone on the post-operative assessment.
The aims of our study were therefore to (a) explore factors predicting the presence of a CBD stone image during upfront surgery, to (b) define the predictors of a stone on the post-operative assessment in patients with an image of a CBD stone on cholangiogram, and to (c) explore the efficiency of a post-operative EUS/ERCP management in case of intra-operative CBD stone discovery.
The study included a retrospective assessment of adult patients (>16 years) with acute gallstone-related disease who had undergone same-stay cholecystectomy from 01.01.2013 to 01.01.2015. Those with a suspected intra-operative CBD stone on cholangiogram were specifically assessed.
Inclusion criteria were: (a) adult patients (>16 years) admitted through the emergency room at the Geneva University Hospitals with a history of acute right upper quadrant pain, (b) radiologically proven gallbladder stone, (c) treatment by cholecystectomy during the same admission, and (d) the absence of CBD investigation prior to cholecystectomy.
Overall, patients presented with (a) prolonged biliary colic, with right upper quadrant pain >6 h, (b) acute cholecystitis with pain, blood signs of inflammation/infection, and a compatible ultrasound assessment, or (c) cholangitis as previously defined . Data were prospectively collected during the hospital stay and analysed at the end of the inclusion period.
Patients could be categorized into three groups according to their risk of presenting a CBD stone following the ASGE/SAGE guidelines . Low-risk patients demonstrated normal LFTs. High-risk patients included those with serum bilirubin ≥ 70 μmol/l, a visible stone on pre-op imaging (ultrasound (US) or computed tomography (CT)), an ascending cholangitis, and those with bilirubin 30–70 μmol/l and CBD diameter >6 mm. Patients at intermediate risk of a CBD stone included those with abnormal LFTs not fulfilling the aforementioned criteria for high risk of a CBD stone. Based on a recent randomized clinical trial, patients at low and intermediate risk of a CBD stone were managed by cholecystectomy first  and represented the target population of patients included in the present study. High-risk patients underwent primary CBD endoscopic exploration followed by cholecystectomy and were not included in the present analysis to improve the population homogeneity.
All patients underwent same-stay laparoscopic cholecystectomy with intra-operative cholangiogram (IOC). Of note, the local policy to systematically performed an IOC is based on safety and didactic reasons, and is aiming at better identifying CBD stones. It is not fully supported by the current literature [8–10]. The cholangiogram looked for a filling defect compatible with a stone, the presence/absence of contrast passage into the duodenum, and a potential iatrogenic bile duct lesion. Patients with a suspected CBD stone on the IOC underwent a post-operative CBD exploration, most often based on endoscopic ultrasound (EUS) followed by endoscopic retrograde cholangiopancreatogram (ERCP) in the case of a confirmed stone. According to the clinical situation, and based on the surgeon’s decision, some patients could be managed with a trans-cystic drain (Escat CH6 drain, Coloplast, Coloplast Group, Denmark).
Variables of interest
The main outcome of interest was the presence of an image of a CBD stone detected on IOC (filling-defect and/or the absence of contrast passage into the duodenum). We further assessed the patients with a confirmed stone on post-operative EUS.
Studied variables included demographic data (age, gender, body mass index (BMI)), admission data (fever, right upper quadrant pain, signs of cholecystitis on US, admission LFTs), and outcome data (length of hospital stay, conversion rate to a laparotomy, complications according to the Dindo/Clavien classification ). In addition, we recorded post-operative LFTs in the patients with an image of a CBD stone on the IOC.
Statistical analysis and ethics
Demographic and admission data were compared between patients with or without the image of a CBD stone on IOC to look for predictors of intra-operative stone. IOC characteristics and post-operative LFTs were compared between patients with or without a confirmed stone on post-operative EUS to identify predictors of a confirmed CBD stone on post-operative EUS. The groups were compared with Student’s t-test and Chi-squared tests. The standard alpha level of .05 indicated statistical significance. Analyses were conducted using SPSS 18.0 (SPSS, Chicago, IL). Ethical approval was obtained from the Institutional Ethical Review Board under the number GE 15–087.
Predictors of a CBD stone on IOC
Demographics and presentation comparing patients with or without a common bile duct stone image on cholangiogram
Total (N = 399)
CBD stone (N = 50)
No CBD stone (N = 349)
Male, No. (%)
Female, No. (%)
Age (mean ± SD), years
56 ± 19
47 ± 20
55 ± 18
BMI (mean ± SD), kg/m2
28 ± 6
29 ± 6
28 ± 5
Fever, No. (%)
RUQ pain on admission, No. (%)
Associated cholecystitis, No. (%)
Admission LFTs (mean ± SD)
167 ± 184
67 ± 146
166 ± 197
68 ± 121
123 ± 97
81 ± 48
245 ± 276
94 ± 139
Total Bilirubin, μmol/L
26 ± 17
20 ± 12
Conjugated Bilirubin, μmol/L
18 ± 10
9 ± 7
Abnormal admission LFTs
ASAT (11–42 IU/L), No. (%)
ALAT (9–42 IU/L), No. (%)
PA (30–125 IU/L), No. (%)
GGT (9–35 IU/L), No. (%)
Total Bilirubin (7–25 μmol/L), No. (%)
Conjugated Bilirubin (2–9 μmol/L), No. (%)
Among the 399 studied patients with upfront cholecystectomy, 50 (12.5%) presented an image of a CBD stone on IOC (Table 1). Such patients were younger (47 vs. 55 years, P = .01) than those without an image of a CBD stone on IOC. In addition, they were less likely to present fever on admission (2 vs. 11.7%, P = .04) or an associated cholecystitis on ultrasound (66 vs. 83.7%, P = .003). Finally, they demonstrated significantly higher admission LFTs (Table 1). We also assessed similar criteria only looking at patients with intermediate risk of CBD stone (demonstrating similar results as when using the entire cohort) (Additional file 1: Table S1).
In the CBD stone group (N = 50), all patients were assessed by IOC. In the No CBD stone group (N = 349), the IOC success rate was 81.4% (284/349). In the 65 patients without IOC, the absence of CBD stone was confirmed by MRCP, EUS, ERCP and by following the LFTs until their normalization, and checking the absence of subsequent management for a CBD stone.
Management of patients with a suspected CBD stone on IOC
One patient underwent intra-operative ERCP with successful stone extraction. Two underwent laparoscopic stone extraction utilizing a Dormia basket. Two patients had a cholangiography through a transcystic drain left during surgery before EUS/ERCP. As this examination was negative, no further endoscopic assessment was performed, and the patients had drain removal a few weeks later.
No CBD stone
(N = 399)
(N = 50)
(N = 349)
Conversion from LS to LT, No. (%)
Laparotomy first, No. (%)
LOS (mean ± SD), days
6.9 ± 4
8.8 ± 4.7
6.6 ± 3.8
Complications (Dindo-Clavien classification)
Grade III, No
Grade IV, No
In the CBD stone group, one patient (1/50, 2%) has been converted from laparoscopy to laparotomy because of adhesions and a stomach sero-muscular lesion. In addition, another patient underwent a laparotomy first due to a patent foramen ovale. In the No CBD stone group, 7 patients had a conversion (7/349, 2%), due to adhesions, severe pediculitis, haemorrhage, small bowel perforation, lack of identification of the cystic duct and necrotized gallbladder with peritonitis. In addition, two other patients underwent a laparotomy first due to severe heart failure and septic shock.
Predictors of a CBD stone on post-operative CBD assessment
Comparison of patients with positive versus negative post-operative endoscopic ultrasound
(N = 17)
(N = 15)
LFTs before EUS
119 ± 120
100 ± 87
151 ± 194
167 ± 117
128 ± 89
86 ± 43
290 ± 265
260 ± 233
Total Bilirubin, μmol/L
24 ± 15
33 ± 28
Conjugated Bilirubin, μmol/L
21 ± 12
31 ± 21
Pancreatic tests before EUS
26 ± 9
108 ± 192
Filling defect present, No.
Contrast in duodenum present, No.
Delay between surgery and post-operative EUS, days
1.8 ± 0.8
1.9 ± 1.4
Impact of a trans-cystic drain
Usefulness and safety of transcystic drainage in patients with an intra-operative suspicion of common bile duct stone
Patients with transcystic drainage (N = 5)
Patients without transcystic drainage (N = 45)
Duodenal passage of contrast product during IOC
Difficult duodenal passage, No.
No duodenal passage, No.
Delay between surgery and post-operative CBD assessment, days
1 ± 0.4
2 ± 1.3
Length of stay (mean ± SD), days
11 ± 8
9 ± 4
Length of transcystic drainage (mean ± SD), days
39 ± 22
Complications (Dindo-Clavien classification)
Grade I, No.
Grade II, No.
Grade III, No.
Grade IV, No.
The risk of a CBD stone is classically defined by a combination of clinical, biological and radiological parameters . The present study assessed patients without previous CBD exploration and confirmed the value of LFTs, and clinical variables such as fever, as well as signs of cholecystitis on US . In addition, women were more likely to present a stone.
Despite these known risk factors, our local policy is to perform an IOC in all patients undergoing cholecystectomy because models predicting the presence of a stone are not accurate enough [10–12]. Alternatively, IOC appears as efficient as ERCP in predicting the presence of a stone [13, 14]. Additionally, it bears a didactic value, training younger surgeons at approaching the CBD for a potential exploration. Finally, IOC also helps to detect an iatrogenic bile duct lesion . We acknowledge, however, that patients with normal LFTs undergoing elective cholecystectomy do not necessarily need an IOC. Conversely, we strongly recommend following the IOC path in patients undergoing cholecystectomy for acute gallstone-related diseases, especially in the case of abnormal LFTs.
Overall, an intra-operative stone was suspected in 12.5% (50/399) of the studied patients, based on IOC abnormalities. The preliminary injection of a limited quantity of contrast agent helps to detect a filling defect, while a stone can be less visible after the injection of a large volume of contrast agent. Of note, manoeuvres such as changing the table position and/or injecting saline help in the differential diagnosis with an air bubble. The second type of abnormality is the lack or a difficult contrast passage into the duodenum, which may be due to a trapped CBD stone, an Oddi’s sphincter spasm, or a lesion of the sphincter (neoplasia/inflammation).
Only half of the suspected stones could be confirmed post-operatively. Based on the current data, it remains difficult to predict which patients will finally present a confirmed stone. Post-operative LFTs have no predictive power. LFTs may remain increased because of the previous injection of contrast during IOC or because a liver lesion occurred during the removal of the gallbladder from its bed. Only the presence of a filling defect tends to be predictive of a remaining CBD stone, whereas the absence of contrast passage into the duodenum is not. Most contrast passage alterations are likely linked to spasms. The net results of these observations are that a post-operative CBD assessment is required in all patients with an IOC abnormality and that LFTs do not necessarily need to be repeated after surgery due to their low predictive value.
We favour the use of post-operative EUS (+/-ERCP) in patients with an image of a stone during same-stay cholecystectomy. In fact, EUS accuracy is very high (near 97%) as are the sensitivity (71–100%), specificity (67–100%) and the positive or negative predictive values [16–19].
Such a strategy allowed the extraction of all stones by ERCP (with the exception of one patient treated by interventional radiology). As an alternative, laparoscopic CBD exploration could also be used. However, it can require the use of laparoscopic choledochotomy, with a risk of bile leak up to 15%, especially in patients with non-dilated CBD, and in the presence of inflammation . In addition, the ERCP stone clearance rate appears higher than that after laparoscopic bile duct exploration [21, 22].
Another option would have been to perform ERCP during surgery (with or without rendezvous) . Here again, we have not selected this strategy primarily because half of the patients do not show a confirmed stone on post-operative tests (and would have undergone unnecessary ERCP). Secondarily, emergency intra-operative ERCP is difficult to organize because of endoscopist availability and the positioning of the patient being non-standard for ERCP. The present study is limited by its retrospective nature and its potential for type 2 errors. However, it provides a real-life assessment of the proposed management strategy of patients at risk of CBD stones.
The present study is limited by its retrospective nature and its potential for type 2 errors. However, it provides a real-life assessment of the proposed management strategy of patients at risk of CBD stones.
As a whole, the present study confirms that same-stay cholecystectomy can (and should) be performed even in the presence of moderately abnormal liver function tests. The cholangiogram suspicion of a CBD stone can be confirmed in only half of the patients (more often in the presence of a filling defect, and less often with the absence of contrast passage). All stones can be safely treated after surgery (most by ERCP).
American Society for Gastrointestinal Endoscopy
Body mass index
Common bile duct
Endoscopic retrograde cholangiopancreatogram
Liver function tests
Length of stay
Magnetic resonance cholangiopancreatography
Right upper quadrant
Society of American Gastrointestinal and Endoscopic Surgeons
CT was supported by the Swiss National Science Foundation (PP00P3_139021).
Christian Toso, MD, PhD, received salary support from the Swiss National Science Foundation (PP00P3_139021). This grant was not given specifically for the present study and was not used to conduct it.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
All authors read and approved the final manuscript. The specific contributions of each author are as follows: SdS: study design, study protocol creation, literature search, data collection, data analysis, data interpretation, figure and table creation, manuscript writing. OT: study design, data collection, manuscript revision. IP: study design, data collection, manuscript revision. J-LF: study design, manuscript revision. PM: study design, manuscript revision. CT: study design, study protocol creation, data analysis, data interpretation, figure and table creation, manuscript correction.
The authors declare that they have no competing interests.
Consent for publication
Ethics approval and consent to participate
Ethical approval was obtained from the Institutional Ethical Review Board under the number GE 15–087. Of note, it has waved the request for a written informed consent from each patient due to the retrospective nature of study, the large number of patients, and the relatively high gain in knowledge compared to the large amount of work required to specifically consent each patient.
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