ERCP

There are no randomized trials to assess the difference in outcomes between surgical exploration of CBD and stone extraction and ERCP ( and there won't be any as surgeons are less involved in CBD exploration ) but i think ERCP is safer and more efficient 

ERCP will be the best option to start with.  It should be followed by a laparoscopic cholecystectomy during the same hospital admission.

ERCP should be the treatment of choice followed by laparoscopic cholecystectomy in same admission. 

ERCP to clear the CBD stones, followed by laparoscopic choleystectomy.

It depends on the availability and local expertise. If in your hospital there is a skilled endoscopist, who usually perform ERCP, endoscopic treatment should be the choice, followed by laparoscopic cholecystectomy (with IOC if endoscopic treatement has failed).

If in your hospital there is a skilled surgeon who usually perform IOC, you can reserve ERCP (eventually intraoperative) in the event of the surgeon's technical difficulty.

In our own practise we definitely start with ERCP, followed by laparoscopic cholecystectomy.

There is not one type of CBD stones  The most common are those migrating from gallblader that should be treated  pre or intraoperative by ERCP or  IOC or even pos by ERCP    however there are stones migrating from intrahepatic biliary ducts or even primary CBD stones  secondary to duct strictures or even choledocal cyst  In cases with cholangitis  we prefer to performed ERCP before cholecystectomy otherwise we usually performed intraoperative ERCP

Symptomatic CBD stones = CBD obstruction with stones. First you need to visualize CBD in any way. You may use ERCP (most often it provides diagnosis and treatment as well), you may use CT, you may perform trans-cutis trans-hepar puncture and fill bile ducts with contrast and then X-ray CBD, you may perform laparoscopy (laparotomy) and IOC, or any other... Whenever you get objective diagnosis, you choose treatment options depending on the availability and local expertise (ref. Vittorio Terruzzi answer, etc).

Good Luck!

I think that treatment of CBD stones should be individualized and tailored to the characteristic of the stone and the clinical condition of the patient.

For this reason it should be done in a setting were all the options are available at high level of procifiency. I also think that this should be the way to go for all medical issues.

ERCP is always the first choice. If failure to ERCP or huge stone,  laparoscopic CBD exploration and stone removal would be the alternative treatment 

The best way is to extract the CBD stone by performing an ERCP with an associated sphinterotomy. There is not another effective medical treatment and is better the endoscopic approach than the surgical of course

So, the best option is ERCP! 

Thank you all for your detailed answers,

Regards,

Osaid

Dear Dr Osaid

I agree with you that ERCP with sphinctertomy  is the best option.

You have the choice of ERCP and then lap chole or lap chole with intra op cholangiogram / cbd clearance. We opt for ERCP generally to clear the duct and then elective cholecystectomy

The first option is to perform an ERCP with sphincterotomy this is the best cost-benefit choice, indeed