[Temporal sequence of bile duct clearance with simultaneous cholecystolithiasis or choledocholithiasis-Preoperative, intraoperative or postoperative?]

Approximately 10% of patients with symptomatic cholecystolithiasis also have choledocholithiasis. The probability of this can be estimated on the basis of sonographic and laboratory chemistry parameters. If the probability is high, endoscopic retrograde cholangiography (ERC) or cholangiopancreatography (ERCP) should be performed and if the probability is low, cholecystectomy can be performed without further diagnostics. If the findings are equivocal, further work-up should be performed to detect or exclude choledocholithiasis by endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP). If choledocholithiasis is detected, it can be treated by ERC preoperatively, intraoperatively or postoperatively or alternatively by laparoscopic cholangiography. Regarding the temporal sequence, there is no clear advantage of a specific time point; however, considering the high availability of ERCP in German-speaking countries, preoperative clearance of choledocholithiasis seems reasonable. With respect to the time interval between clearance of choledocholithiasis and cholecystectomy, a number of multicenter studies and a meta-analysis have shown that a short time interval or a procedure during the same period of hospitalization is advantageous.