This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2020.
By Vimal K. Narula, Eleanor C. Fung, D. Wayne Overby, William Richardson, Dimitrios Stefanidis and the SAGES Guidelines Committee
Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis.Â A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis.The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis.
Choledocholithiasis, ERCP, Common bile duct exploration, Management, Diagnosis
Choledocholithiasis has a prevalence of approximately 10â15% of patients with symptomatic cholelithiasis . The clinical presentation of choledocholithiasis can range from completely asymptomatic to biliary colic and symptoms of obstructive jaundice, such as pruritus, dark urine and acholic stools. Although up to a third of patients with common bile duct (CBD) stones will pass them spontaneously without intervention, the majority of patients will require endoscopic and/or surgical intervention . The objective of this document was to review best practices in the diagnosis and management of patients with common bile duct stones.
The working group first determined questions relevant to the clinical practice of surgeons treating patients with choledocholithiasis. It then conducted a PubMed search of all English language articles in October 2019 published using the medical subject heading (MeSH) search terms âcommon bile duct stonesâ, âcholedocholithiasisâ, âERCP/endoscopic retrograde cholangiopancreatographyâ, âcommon bile duct explorationâ, âdiagnosisâ and âmanagementâ. A total of 725 articles were found and reviewed by the working group; after exclusion of studies not relevant to our clinical questions 79 full manuscripts were reviewed in detail. Articles pertaining to management strategies for choledocholithiasis and best clinical scenarios for the application of each strategy are summarized below under each question. Comparative evidence was sought where available.
What investigations should be performed in patients with suspected choledocholithiasis?
For all patients with suspected choledocholithiasis, obtaining liver transaminases, bilirubin and a transabdominal ultrasound are recommended as preliminary investigations to identify patients with high likelihood of common bile duct stones. Ultrasound findings consistent with choledocholithiasis include visualization of a common bile duct stone and a dilated common bile duct greater than 8-mm . The combination of clinical presentation, laboratory results, and imaging findings should be considered when deciding on next steps of management and investigations.
If the diagnosis of choledocholithiasis is still in question following these tests, magnetic resonance cholangiopancreatography (MRCP) is a non-invasive option, which has a sensitivity ofâ>â90% and specificity nearing 100% . However, the main disadvantage of MRCP is that common bile duct stones identified require intervention by another method to be removed. Other diagnostic modalities to detect common bile duct stones include endoscopic ultrasound (EUS) in which an echo endoscope is positioned in the duodenal bulb in which the average sensitivity and specificity is approximately 95 and 97%, respectively . Although the interpretation of EUS and MRCP are both subject to bias, meta-analyses have found an observed superiority in the sensitivity of EUS as compared to MRCP due to better accuracy of EUS in detection of small stones and as such, EUS-directed ERCP has been advocated as a cost-effective method since both EUS and ERCP could be performed in the same session.
What is the pre-test probability of choledocholithiasis in my patient?
Numerous factors have been implicated as prognostic predictors to help stratify patients into low, intermediate and high probability of choledocholithiasis. The visualization of a common bile duct stone on abdominal ultrasound carries approximately a 73% sensitivity and 91% specificity according to a meta-analysis of five studies . Other strong predictors for choledocholithiasis include clinical evidence of acute cholangitis, a bilirubin greater than 1.7Â mg/dL and a dilated CBD; the presence of two or more of these factors has a pre-test probability of 50%-94% for choledocholithiasis (considered high) [7,8]. Patients without evidence of jaundice and a normal bile duct on ultrasound have a low probability of choledocholithiasis (<â5%) . Patients that fall between these two spectrums are categorized as having an intermediate probability of choledocholithiasis. The algorithm presented in Fig.Â 1Â may be helpful for managing patients with suspected choledocholithiasis dependent on their risk stratification.
Management algorithm for patients based on probability of choledocholithiasis
How should patients with documented choledocholithiasis be treated?
The management of choledocholithiasis depends on the timing of common bile duct stone discovery in relation to the cholecystectomy. The algorithm presented in Fig.Â 2Â demonstrates the recommended approach to choledocholithiasis dependent on whether it is discovered pre-operatively, intraoperatively or post-operatively.
Treatment algorithm for patients with documented choledocholithiasis based on time of diagnosis
What is the pre-operative management of choledocholithiasis?
If the diagnosis of choledocholithiasis is confirmed pre-operatively, there are options of clearance of the CBD which include endoscopic retrograde cholangiopancreatography (ERCP) prior to cholecystectomy or common bile duct exploration combined with cholecystectomy which is described in the next section.
ERCP is highly sensitive and specific for choledocholithiasis with the added benefit of being therapeutic to clear stones from the biliary tree in an attempt to avoid common bile duct exploration and prevent distal obstruction. By directly cannulating the ampulla to access the biliary tree, a sphincterotomy is often performed with sweeping and extracting stones from the common bile duct. ERCP has a success rate of approximately 80â90% for ductal clearance with proper expertise. Reasons for failure include large or impacted stones, duodenal diverticula, altered gastric or duodenal anatomy and intrahepatic stones. Risks associated with ERCP include pancreatitis (1.3â6.7%), infection (0.6â5%), hemorrhage (0.3â2%), perforation (0.1â1%) and mortality (up to 1%) . Following biliary clearance with ERCP, it is generally recommended to proceed with subsequent cholecystectomy to prevent the occurrence of recurrent episodes of symptomatic cholelithiasis which occurs in approximately 20% of patients. However, in patients with advanced comorbidities who are at significantly high risk for operative intervention, ERCP with sphincterotomy without any further subsequent intervention can also be considered definitive therapy, as there has been no statistical difference in mortality [11,12].
What is the intraoperative management of choledocholithiasis?
The diagnosis of choledocholithiasis can be confirmed intraoperatively during an intraoperative cholangiogram (IOC) or laparoscopic ultrasound (LUS). The standard IOC method includes cannulation of the cystic duct or gallbladder with a fine catheter and direct injection of contrast to visualize the common bile duct and biliary tree . Laparoscopic IOC has an approximate sensitivity of 75â100% and a specificity of 76â100% [14,15]. When choledocholithiasis is confirmed intraoperatively, a decision should be made between common bile duct exploration at the time of cholecystectomy and post-operative ERCP, which is dependent on local availability of surgical and endoscopic expertise. Both IOC and LUS also allow for evaluation of biliary anatomy which can aid in determining the optimal approach for biliary clearance. Furthermore, laparoscopic common bile duct exploration is contraindicated in the absence of common bile duct pathology, in patients with hemodynamic instability, or when a hostile porta hepatis is encountered intraoperatively .
Laparoscopic common bile duct exploration combined with cholecystectomy is a feasible and effective option as a single-stage procedure for the management of choledocholithiasis. A Cochrane review on the topic has shown that single-stage laparoscopic common bile duct exploration with cholecystectomy and two-stage ERCP followed by laparoscopic cholecystectomy have similar efficacy rates in clearing the CBD with no significant difference in patient morbidity and mortality . Although the single-stage laparoscopic approach was found to have a longer average operative time, it was associated with a shorter overall hospital stay and need for fewer procedures, making it a more cost-effective method for the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy .
Common bile duct exploration was traditionally performed as an open procedure but can be performed laparoscopically either via a transcystic approach or transductal approach. Nevertheless, laparoscopic common bile duct exploration has not been adopted widely as it is technically challenging and strongly dependent on surgeon experience and equipment availability . However, a simulation-based mastery learning curriculum has been shown to increase the clinical utilization, skill acquisition and adoption of laparoscopic common bile duct exploration . While the results of this study are promising, the most important consideration when deciding on the treatment of choledocholithiasis for an individual patient are expertise in the procedure, characteristics of the biliary tree, and local availability of resources.
For the laparoscopic transcystic approach, a transverse opening is made in the cystic duct prior to its transection. The common bile duct can then be accessed with a small-bore catheter for saline flushes, which may be successful in dislodging stones into the duodenum. 1â2Â mg IV glucagon can also be administered to relax the Sphincter of Oddi to facilitate passage. If this is not successful, stones can be extracted with a wire basket or Fogarty balloons under fluoroscopic guidance. If the initial ductotomy made for cholangiogram is too small, the ductotomy can either be extended closer to the cystic duct-CBD junction or pneumatic cystic duct dilatation can be performed under fluoroscopy over a guidewire. Alternatively, a small caliber choledochoscope with a working channel can be passed through the cystic duct into the common bile duct where a basket stone extractor can then be used to capture the stones under direct visualization .
If the stones cannot be cleared intraoperatively, laparoscopic transcystic biliary stent placement can be performed under fluoroscopic guidance which can facilitate biliary drainage and allows for post-operative ERCP to be performed electively and more successfully. Alternatively, a flexible guidewire can be placed intraoperatively through a cystic ductotomy into the biliary tree across the ampulla into the duodenum under fluoroscopy to allow for ERCP via a ârendez-vousâ procedure, in which the duodenoscope can then be inserted per os to capture the guidewire. A biliary sphincterotome can then be back-loaded over the guidewire to allow for direct cannulation of the common bile duct followed by stone extraction through a single-stage laparoscopic-endoscopic approach .
Relative contraindications to the transcystic approach include a small, friable cystic duct, multiple stones in the common bile duct, stones larger than 1Â cm or stones in the proximal duct [16,22]. The success rate of stone clearance via a transcystic approach can reach up to 71% .
A transductal approach can be attempted laparoscopically if the surgeon has the needed expertise and if the common bile duct is at least 7Â mm in diameter to reduce the risk of post-operative stricture. The anterior surface of the distal CBD is identified and incised longitudinally to access the common bile duct. Saline flushes, Fogarty catheters, stone retrieval baskets and the choledochoscope can then be used to facilitate clearance of the common bile duct. The choledochotomy can then be closed either primarily using absorbable 4â0 or 5â0 sutures or over a T-tube, an antegrade biliary stent or with an external biliary drain depending on the surgeonâs discretion and the clinical situation depending on the potential risk of post-operative CBD stricture, increased pressure within the CBD leading to bile leak or retained common bile duct stones .
If a T-tube is used, the T-tube is left to gravity drainage post-operatively for 1Â week and imaged with T-tube cholangiography prior to consideration of removal. The T-tube can also be given a trial of clamping over a 1Â week period prior to discharge and in the absence of jaundice, fevers and elevation of liver transaminases, the tube can remain clamped over 1Â week and subsequently be removed at 2Â weeks post-operatively without cholangiography in the absence of symptoms .
Complications of common bile duct exploration include retained stones (0â5%), bile leak (2.3â26.7%), common bile duct stricture (0â0.8%) and pancreatitis (0â3%). We suggest that the reader also reviews the SAGES clinical spotlight review on laparoscopic common bile duct exploration for further details .
If plans are made intraoperatively for post-operative ERCP for common bile duct stone clearance, additional measures, such as endoloops or additional laparoscopic clips on the cystic duct stump and an external drain in the gallbladder fossa, should be considered to protect against leakage of the cystic duct stump due to the higher pressures present in the biliary tree.
What is the post-operative management of choledocholithiasis?
If the patient is found to have a retained stone post-operatively, ERCP is the treatment of choice for biliary clearance. In the case that endoscopic retrieval is unsuccessful, percutaneous biliary drainage or less frequently laparoscopic or open common bile duct exploration may be required.
What are special considerations in the management of choledocholithiasis?
Patients with choledocholithiasis that present challenges include those with recurrent CBD stones, large or impacted stones, altered gastric or duodenal anatomy such as Billroth II or Roux-en-Y gastric bypass and those presenting with sepsis secondary to acute cholangitis.
What are the approaches to recurrent common bile duct stones?
Patients with recurrent stones pose a challenge in the management of choledocholithiasis. Risk factors for recurrent stones include multiple common bile duct stones, biliary dilatationâ>â13Â mm, prior open cholecystectomy, prior gallstone lithotripsy, hepatolithiasis or factors leading to biliary stasis such as periampullary diverticula, papillary stenosis, biliary stricture or tumor and angulation of the common bile duct. Treatment of recurrent common bile duct stones typically includes repeat endoscopic intervention (i.e., ERCP) but may also be treated surgically in patients who are at high risk of recurrence. The three main surgical options for re-establishing biliary drainage include choledochoduodenostomy, hepaticojejunostomy or transduodenal sphincteroplasty, which should be further pursued with involvement of a hepatopancreatobiliary surgeon .
What techniques can be employed to manage large or impacted stones?
Traditionally, patients with CBD stones that were unable to be extracted endoscopically would have to undergo common bile duct exploration. However, there are a variety of other minimally invasive techniques that can be employed prior to surgical intervention.
What if the biliary system cannot be cannulated during ERCP or surgery?
If the patient is found to have documented choledocholithiasis pre-operatively and a pre-operative ERCP is pursued without successful cannulation of the biliary tree, a pre-cut sphincterotomy can be considered, in which a needle-knife with electrocautery is used to score the region of the papilla for access. This has been associated, however, with an increased complication rate of 5â30%, which include perforation and post-ERCP pancreatitis . Another well-reported method includes the staged ârendez-vousâ procedure in which the interventional radiologist is able to place a percutaneous transhepatic guidewire that is fed retrograde through the papilla into the duodenum that can then be accessed by the duodenoscope for cannulation . Endoscopic ultrasound-guided biliary drainage via choledochoduodenostomy is also another documented method of accessing the common bile duct in which the common bile duct is directly punctured via a transduodenal approach to both clear and stent the common bile duct but this does require advanced endoscopic expertise .
If the patient is found to have choledocholithiasis intraoperatively and the biliary tree cannot be successfully cannulated for stone extraction, a post-operative ERCP, further surgical attempts via laparoscopic or open techniques or percutaneous biliary drainage can be pursued depending on local expertise and resource availability (Fig.Â 2). This is described in more detail in the SAGES clinical spotlight review on laparoscopic common bile duct exploration .
What if I am unable to extract the stone during ERCP or surgery?
If the patient is undergoing a pre-operative ERCP and endoscopic attempts with balloon or basket sweeping are unsuccessful, mechanical lithotripsy by way of capturing and fragmenting stones with a reinforced basket with a spiral sheath can be successful in over 80% of cases [28,29]. There are also through the scope choledochoscopes (e.g., Spyglass) that are now available that can administer intracorporeal electrohydraulic or laser lithotripsy. In this method, energy is delivered directly to a large or impacted stone under direct visualization with the aid of continuous irrigation of the CBD. Electrohydraulic lithotripsy involves shock waves that are delivered in brief pulses directly at the stone by the probe, which is optimally located approximately 1â2Â mm from the stone. Laser lithotripsy involves laser light of a high-power density, traditionally Holmium:Yttrium-aluminum-garnet (YAG) laser, is aimed directly on the surface of a stone, creating a plasma gaseous collection of ions and free electrons that then induces oscillation and cavitation that shatter the stone surface .
If intraoperative laparoscopic attempts for stone clearance are unsuccessful due to technical reasons, ampullary edema or distal stricturing, an antegrade ampullary stent can be inserted laparoscopically under fluoroscopic guidance either through a transcystic or transcholedochal approach and allows for post-operative ERCP to be performed (Fig.Â 3). This laparoscopically deployed stent sits across the ampulla in which the internal flap is within the common bile duct and the external flap is within the duodenum with no externalization of drainage; if the stent is deployed transcystically, the cystic duct stump can then be ligated with either laparoscopic clips or endoloops. Alternatively, a flexible guidewire can be placed intraoperatively across the ampulla to allow for concomitant ERCP via a single-stage laparoscopic-endoscopic ârendez-vousâ procedure as described earlier. The SAGES clinical spotlight review on laparoscopic common bile duct exploration can be referenced for further discussion .
Example of an antegrade common bile duct stent that can be inserted laparoscopically under fluoroscopic guidance to allow for biliary drainage, if biliary clearance cannot be achieved intraoperatively. The stent is deployed across the ampulla such that the internal flap is within the common bile duct and the external flap is within the duodenum. Image permissions obtained from Cook Medical and Boston Scientific
If these methods continue to be unsuccessful and the stone is unable to be retrieved, the short-term use of a temporary biliary stent either placed endoscopically, intraoperatively or percutaneously via interventional radiology can be used to ensure adequate biliary drainage followed by further attempts at ERCP or surgery.
What are non-endoscopic, non-surgical options for achieving biliary decompression?
If endoscopic measures are truly unsuccessful, there are a few options prior to surgical management, which include percutaneous radiologic treatment, extracorporeal shock wave lithotripsy and dissolution therapy.
Percutaneous transhepatic biliary drainage (PTBD), although mainly used in cases of malignancy, can be considered an accepted alternative method for biliary decompression if the intrahepatic bile ducts are dilated and if other methods of stone extraction have failed. Either a temporary external drain, an internal/external biliary drain or an internal stent can be used to achieve biliary drainage (Fig.Â 4). This technique is particularly attractive in the setting of sepsis secondary to acute cholangitis in the patient that is hemodynamically unstable and thus, unfit for endoscopic or surgical intervention. In addition to percutaneous drainage, the creation of a transhepatic fistula can then allow for the use of adjuncts via the drain tract such as basket retrieval, electrohydraulic or laser lithotripsy and the ârendez-vous procedureâ following dilation of the tract (techniques described above) . Although these techniques have high success rates, there is a significant risk of bleeding via the transhepatic tract and it can also cause patient discomfort as well as dehydration secondary to fluid losses.
Percutaneous biliary interventions that can be inserted by interventional radiology.Â AÂ Example of a percutaneous transhepatic biliary drain which can either be an external biliary drain in the intrahepatic ducts or an internal/external biliary drain that traverses the ampulla into the duodenum.Â BÂ Example of an internal biliary stents that can be placed percutaneously under fluoroscopic guidance. Credits to BSIR and Boston Scientific for permission to use the images of the internal/external biliary drain and biliary stents
Extracorporeal shockwave lithotripsy (ESWL) involves high-pressure electrohydraulic or electromagnetic energy that is delivered through a liquid or tissue medium to the designated target point to fragmenting stones. A naso-biliary drain is inserted by radiology to allow for fluoroscopic identification and targeting of the common bile duct stones. The energy setting and number of discharges delivered is dependent on the device used and patient tolerance as the main adverse effects include pain, local hematoma formation, cardiac arrhythmias, biliary obstruction, hemobilia and hematuria . Furthermore, ESWL has particular contraindications, such as portal thrombosis and varices of the umbilical plexus . Despite a ductal clearance success rate of approximately 60â90%, it is not considered a first-line treatment for difficult stones and is uncommonly used.
Lastly, administration of oral ursodeoxycholic acid has been documented to have a potential role in facilitating stone clearance by reducing the size of common bile duct stones that are unable to be retrieved endoscopically . The effective dose of ursodeoxycholic acid is between 8 and 12Â mg/kg daily for several months. However, its role in preventing the formation of common bile duct stones is still unclear.
What techniques can be employed in patients with altered gastric or duodenal anatomy?
Patients with choledocholithiasis with altered anatomy, particularly with Billroth II or Roux-en-Y gastric bypass, pose significant challenges for biliary clearance due to the inability to access the biliary tree in the conventional transoral manner. This has been increasing in frequency due to the popularity of gastric bypass surgery, and is also seen in patients following gastric resection surgery, Whipple procedure or liver transplantation.
Balloon-assisted ERCP or endoscopic ultrasound-directed transgastric ERCP (EDGE procedure) can be attempted but both require advanced endoscopic expertise. In balloon-assisted ERCP, the enteroscope has a working length of 200Â cm and the 12-mm diameter Overtube has a length of 140Â cm. By alternating inflating and deflating the balloons and straightening the scope with the Overtube, the endoscope is progressed stepwise through the small intestine under fluoroscopic guidance and maneuvered into the biliopancreatic limb to access the ampulla . Due to the difficulty in navigation and subsequent cannulation, balloon-assisted ERCP is not always technically feasible for biliary duct clearance in these patients. As such, the EDGE procedure can be an alternative method of accessing the biliary tree in which an anastomosis is created typically with a lumen-apposing metal stent between the gastric pouch or jejunum to the excluded stomach under endoscopic ultrasound visualization which allows a duodenoscope to be passed to perform a conventional ERCP  (Fig.Â 5). Although studies show EDGE to be safe and effective, there are concerns regarding persistent gastrogastric fistula and weight gain following stent removal in which it is recommended that either an upper endoscopy or upper GI series be obtained in all patients post-stent removal to determine the presence of persistent fistula. If present, argon plasma coagulation and over-the-scope clip placement or revisional surgery with gastrogastric fistula takedown may be required for fistula closure . Additional data on the long term outcomes of this procedure (i.e., how many patients develop gastrogastric fistulae?) are needed before it can be widely endorsed. Alternatively, laparoscopic-assisted transgastric ERCP can be used to access the biliary tree in gastric bypass patients in which the gastric remnant is accessed laparoscopically and the duodenoscope is inserted through a gastrotomy made through the gastric remnant  (Fig.Â 6).
Depiction of endoscopic ultrasound-directed transgastric ERCP (EDGE) to perform ERCP following Roux-en-Y gastric bypass. The excluded stomach is located endosonographically from the gastric pouch or afferent limb and accessed to deploy a lumen-apposing metal stent into the excluded gastric remnant to allow antegrade passage of a duodenoscope through the fistula where conventional ERCP can be performed to access and cannulate the ampulla and biliary tree. Image permissions obtained from Dr. Prashant Kedia
Depiction of laparoscopic transgastric access of the gastric remnant to perform ERCP following Roux-en-Y gastric bypass. A 15Â mm port is placed into the greater curvature of the bypassed gastric remnant where the conventional duodenoscope can then be inserted and advanced to the duodenum to access and cannulate the ampulla and biliary tree. Image permission obtained from Gastrointestinal Endoscopy and Elsevier 
If these endoscopic approaches prove unsuccessful, a common bile duct exploration or PTBD with its associated percutaneous interventions can then be performed for common bile duct clearance, which have been described earlier in this document.
How should patients presenting with sepsis secondary to cholangitis be managed?
Once the diagnosis of acute cholangitis has been definitively made in this subset of patients presenting with sepsis, initial treatment includes IV fluid resuscitation with careful monitoring of hemodynamic status. Following this, immediate antimicrobial therapy targeted to the biliary tract and biliary drainage are the key goals of the treatment of acute cholangitis . The treatment strategy for biliary drainage should be decided in consideration of the patientâs general status. In patients who do respond to initial sepsis management, early internal drainage by transpapillary biliary drainage during ERCP should be considered first-line as it not only achieves biliary drainage but also allows for stone removal. If the stones cannot be extracted concurrently with biliary drainage in these critically ill patients, two-session treatment can be pursued with endoscopic biliary stenting performed as initial treatment followed by endoscopic stone removal after improvement of cholangitis . However, in the event of failure of endoscopic techniques or in patients with rapid deterioration and sepsis-induced organ damage, percutaneous transhepatic biliary drainage should be considered as described earlier in this review. Surgical drainage and management is generally rare and not advocated in these critically ill patients due to the increased morbidity and mortality compared to endoscopic treatment in this patient population .
Choledocholithiasis is a commonly encountered diagnosis for general surgeons.
The subtleties in the management of common bile duct stones relate to the decision making on the probability of choledocholithiasis based on clinical presentation and investigations, the timing of presentation in relation to laparoscopic cholecystectomy in addition to the availability of technology and expertise of the surgeons, endoscopists and interventional radiologists. Regardless, the surgeon must be familiar with all possible options at their disposal for managing the patient presenting with choledocholithiasis which are highlighted in this document.
Eleanor C. Fung is a consultant for Boston Scientific and has received travel reimbursements from Cook Medical and Fujifilm. Vimal K. Narula, D. Wayne Overby, William Richardson, and Dimitrios Stefanidis have no conflicts of interest or financial ties to disclose.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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This document was prepared and revised by Vimal K. Narula, Eleanor C. Fung, D. Wayne Overby, William Richardson, Dimitrios Stefanidis and the SAGES Guidelines Committee
This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Feb 2020.
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Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.
Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.