37 © Springer International Publishing Switzerland 2016 J.W. Hazey et al. (eds.), Multidisciplinary Management of Common Bile Duct Stones, DOI 10.1007/978-3-319-22765-8_5 Making the Diagnosis: Surgery, a Rational Approach to the Patient with Suspected CBD Stones Robert D. Fanelli and Brandon D. Andrew R.D. Fanelli, M.D., M.H.A., F.A.C.S. (*) Department of Surgery, The Guthrie Clinic, Sayre, PA, USA Clinical Professor of Surgery, The Commonwealth Medical College, Scranton, PA, USA Clinical Professor of Surgery, SUNY Upstate Medical University, Binghamton, NY, USA Professor of Surgery, Albany Medical College, Albany, NY, USA B.D. Andrew, M.D. Department of Surgery, The Guthrie Robert Packer Hospital Residency Program in Surgery, Sayre, PA, USA 5 Introduction Choledocholithiasis is a frequent complication of gallstone disease, occurring in 5–15 % of patients undergoing cholecystectomy. The risk of choledo- cholithiasis increases with age, with common bile duct stones (CBDS) identified in 30–60 % of patients over age 70 who are undergoing cholecys- tectomy. CBDS often are occult and asymptomatic, and are not associated with biochemical abnormal- ities [1–3]. It appears that as many as 30 % of CBDS will be passed spontaneously, but it is not possible to predict reliably which patients will pass stones spontaneously, or if all CBDS will be passed without intervention. CBDS are a significant prob- lem because they may cause pancreatitis, jaundice, and ascending cholangitis, and may lead to signifi- cant morbidity, and even mortality. CBDS can be classified into primary stones and secondary stones. Primary stones are those which form in the intrahepatic or extrahepatic bile ducts, and largely are composed of calcium biliru- binate and small amounts of cholesterol and cal- cium salts; these also are referred to as pigment stones. Secondary CBDS are those that form in the gallbladder, largely composed of cholesterol, bile salts, and phospholipids, and then advance into the common bile duct through the cystic duct. In the USA, secondary CBDS are much more common than primary CBDS. Principles of Management CBDS can be managed preoperatively, intraop- eratively, or postoperatively. The determination as to when CBDS are addressed largely depends on when CBDS are identified. Therefore, in order to pursue the most efficient approach to the man- agement of CBDS, a high degree of suspicion must be maintained when evaluating and treating patients with gallstone disease, especially those considered to be at a higher than average risk for CBDS. The primary goal in treating patients with gallstone disease in general is to reduce the likeli- hood of recurring symptoms, and to limit the likelihood of related comorbid conditions like sepsis and pancreatitis. Our goal as surgeons is to ensure the lowest possible rate of untreated