Protocol for choledocholithiasis at emergency surgery study (ProCESS)

A cohort study to evaluate a management protocol for CBD stones within the Acute General Surgery Unit (AGSU). Outcome data will be recorded from patients with bile duct stones undergoing emergency laparoscopic cholecystectomy. Management of CBD stones: Laparoscopic bile duct exploration can be considered for all patients irrespective of stone size and number. If the surgeon is unwilling or unable to clear the bile duct at the time of cholecystectomy then further management is determined by stone size and number as well as the presence of absence of biliary obstruction as evidenced by jaundice (bilirubin >40mmol/litre) CBD stone size is estimated with reference to an Olsen-Reddick laparoscopic grasper (width 4.5mm). Group A: Solitary stones < 4.5mm with no biochemical evidence of biliary obstruction Laparoscopic bile duct exploration or conservative management of CBD stones, at the discretion of the operating surgeon. Group B: Stones > 4.5mm, multiple stones or biochemical evidence of biliary obstruction CBD exploration or transcystic stenting at the discretion of the operating surgeon. Exploration may be performed via the transcystic (through the cystic duct) or transductal (via incision into the CBD) route, with or without choledochoscopy. Positioning is checked by intraoperative x-ray. With good stent positioning and biliary drainage, patients may be discharged postoperatively without further investigation or treatment and booked for an elective ERCP. We expect the elective ERCP to be booked within 4-6 weeks of discharge, and our time of follow up ends after successful bile duct clearance via ERCP. This protocol will be undertaken in the unit regardless of the study occurring, as this is already in line with standard practice for many of the surgeons.