Introduction
Methods to clear CBDS carry varying risk of adverse effects while leaving them in situ can lead to complications secondary to retained stones.1–3 Thus, the modality of choice reasonably affects the assessment of whether an attempted removal of asymptomatic CBDS is feasible and adequate. In Sweden, available methods to clear common bile duct stones identified on intraoperative cholangiography during cholecystectomy are flushing/manipulating with cholangio catheter, trans cystic stone extraction, intra-operative endoscopic retrograde cholangiopancreatography (IOERCP), postoperative ERCP, laparoscopic choledochotomy, open choledochotomy and leaving the stone in situ.
Aims & Methods
This observational cohort study was based on the national Swedish Register for Gallstone Surgery and ERCP (GallRiks) with validated prospectively assembled data for 90% of all cholecystectomies and ERCP procedures in Sweden from 2009 to 2023.4 The aim was to assess efficacy and safety of the respective methods of clearing CBDS by estimating their odds ratio (OR) of failing to reach textbook outcome. Leaving CBDS in situ was considered reference method.
Textbook outcome was defined as cholecystectomy and CBDS clearance laparoscopically completed in one session without immediate or 30-day surgical complications (bleeding from wound or GI tract, wound dehiscence, wound infection, sepsis, bile duct injury with or without leakage or bleeding), readmissions, reinterventions, stent placement or prolonged postoperative hospitalization beyond three days.
The size of CBDS was categorized as small (<4mm) intermediate (4-8 mm) and large (>8mm). Patients were considered asymptomatic if no previous or current sign of bilirubinemia, cholangitis or pancreatits was recorded.
Results
Among the 192 203 patients in the register between 2009 and 2023, 25 295 patients presented with a CBDS during cholecystectomy. Failure to achieve textbook outcome was seen for 12 147 (48%) across all stone sizes and management options. Odds ratio of failing textbook outcome when adjusting only for CBDS size was 0.7 (95%CI 0.63-0.77) for intraoperative ERCP and 0.63 (95% CI 0.55-0.71) for transcystic extraction while flushing and manipulating the stone had OR 0.5 (95% CI 0.44-0.57). Laparoscopic choledochotomy had OR 14.36 (95% CI 8.83- 25.09) to fail textbook outcome. All compared to leaving the stone in situ.
For a subgroup of asymptomatic stones smaller than 4mm the flushing manipulating option was the only one beneficial compared to leaving them in situ with unadjusted OR 0.73(95% CI 0.59-0.90) of failing textbook outcome.
Conclusion
This study introduces a novel composite outcome measure—textbook outcome—to define successful, complication-free clearance of common bile duct stones (CBDS) encountered during cholecystectomy. Using this measure, the greatest benefit was seen in the flush/manipulate group, which was also the only approach that provided a clear advantage for small asymptomatic stones compared to leaving them in situ.
Balancing safety and efficacy of CBDS clearance methods remains essential, given the potential for complications associated with interventions in the common bile duct.
Importantly, small asymptomatic stones did not seem to benefit from more invasive removal techniques beyond flushing and manipulation with the cholangiocatheter,
when evaluated using this composite outcome measure. However, these results need to be interpreted with caution due to the risk of selection bias.
References
1 Lammert F, Gurusamy K, Ko CW, Miquel J-F, Méndez-Sánchez N, Portincasa P, et al. Gallstones. Nat Rev Dis Primers [Internet]. Nature Publishing Group; 2016 Apr 28 [cited 2023 Nov 6]; 2: 1–17. Available from: https://www.nature.com/articles/nrdp201624
2 Saito H, Kadono Y, Shono T, Kamikawa K, Urata A, Nasu J, et al. Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones. World J Gastroenterol [Internet]. 2021 May 14 [cited 2023 Oct 24]; 27: 2131–2140. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117734/
3 Berg LS, Friis-Andersen H, Zinther NB, Öztoprak M, Gotschalck KA. Feasibility and outcome of transcystic laparoscopic common bile duct exploration as first-line treatment for common bile duct stones: a retrospective cross-sectional study. Surg Endosc [Internet]. 2025 Feb 11 [cited 2025 Feb 17]; 1–11. Available from: https://link.springer.com/article/10.1007/s00464-025-11587-7
4 Enochsson, L. S G. GallRiks Annual Reports 2018 [Internet]. 2019 [cited 2019 Oct 3]. Available from: https://www.ucr.uu.se/gallriks/fou/arsrapporter/arsrapport-2018-2/viewdocument/837
