Laparoscopic common bile duct exploration versus pre or post-operative ERCP for common bile duct stones in patients undergoing cholecystectomy: Is there any difference?

Abstract

A best evidence topic in surgery was written according to a structured protocol. The question addressed was: in patients with symptomatic gallstones and concomitant common bile duct (CBD) stones, is a single-stage surgical strategy (laparoscopic cholecystectomy (LC) with common bile duct exploration) preferable, or a two-stage procedure involving LC with pre or post-operative endoscopic retrograde cholangiography (ERCP)? Two hundred and six papers were found using the reported search, of which four presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. A recent large meta-analysis concluded no significant difference in the clinical effectiveness or complication rate of either strategy. Three recent smaller studies concurred with this conclusion; however each noted improved cost-effectiveness of the single-stage approach advocating its use as the superior strategy when local resources and expertise are available. We conclude that for patients with symptomatic gallstones and concomitant choledocholithiasis, a single-stage surgical procedure is equivalent to two-stage LC and ERCP in terms of clinical outcomes, is associated with a shorter overall hospital stay and may be more cost-effective. On this basis a single-stage procedure is recommended for management of symptomatic gallstones and choledocholithiasis where local resources and expertise permit.

A two-stage versus single-stage procedure for the management of cholecysto-choledocholithiasis in elderly patients: a retrospectively cohort study

“…Re-intervention within 90 days after the first procedure of stone extraction is associated with a 14-fold increased risk of death (27), which underlines the importance of a successful first therapeutic strategy for avoiding residual and recurrent choledocholithiasis. (28,29). Furthermore, LCBDE is an effective technique for choledocholithiasis with a proven safety and excellent outcome for elderly patients (30).…”

Updated guideline on the management of common bile duct stones (CBDS)

“…There are now a sufficient number of studies to determine that there is no significant difference in clinical outcomes77 117 118 between LBDE and laparoscopic cholecystectomy combined with preoperative or postoperative ERCP. Studies have shown that single-stage LBDE is associated with a reduction in overall hospital stay and cost compared with the two-stage approach of ERCP and laparoscopic cholecystectomy 119 120.…”

Evaluation of different methods of laparoscopic treatment of common bile duct stones

“…5 However, managing CBD stones remains controversial, with the debate between a single-stage procedure in the form of laparoscopic common bile duct exploration (LCBDE) with cholecystectomy and two-stage procedure using endoscopic retrograde cholangio pancreatography (ERCP) either before or after cholecystectomy. 6 The utilization of LCBDE is gradually increasing and is being accepted for CBD clearance; it is associated with reduced hospital stay compared to preoperative ERCP followed by laparoscopic cholecystectomy. 7 However, as LCBDE needs more advanced laparoscopic skills, and manipulation of the flexible choledochoscpe, the preferred procedure in many hospitals remains to do ERCP either before or after laparoscopic cholecystectomy.…”