STEP 3Stone clearance assessment

The assessment of complete stone clearance is performed in two different ways:

■ By control cholangiography.

■ By using flexible choledochoscopy (A-1, A-2): the scope is introduced under fluoroscopic or visual guidance into the CBD to assess the presence of residual CBDs. When used through a TC approach, choledochoscopic stone clearance assessment is usually only possible in the lower part of the CBD, except in the case of a wide angle of insertion of the CD into the CBD. In this case (15-20 % of cases), the scope can be guided into the upper part of the biliary tract.

In case of residual CBDS, an additional endoscopic attempt at stone extraction can be performed by introducing a Dormia basket through the operative channel of the scope, and also by guiding stone capture under visual control. When the number of stones is limited and when stone clearance is complete, the CD can be primarily clipped.

When doubt exists about the completeness of stone clearance, the CBD can be drained by using a transcystic duct drain, carefully secured with an endoloop or an extracorporeal suturing technique.

A-2

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