Surgical Endoscopy

, Volume 32, Issue 9, pp 3763–3776 | Cite as

Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis

  • Anand Narayan Singh
  • Ragini KilambiEmail author



The ideal management of common bile duct (CBD) stones associated with gall stones is a matter of debate. We planned a meta-analysis of randomized trials comparing single-stage laparoscopic CBD exploration and cholecystectomy (LCBDE) with two-stage preoperative endoscopic stone extraction followed by cholecystectomy (ERCP + LC).


We searched the Pubmed/Medline, Web of science, Science citation index, Google scholar and Cochrane Central Register of Controlled trials electronic databases till June 2017 for all English language randomized trials comparing the two approaches. Statistical analysis was performed using Review Manager (RevMan) [Computer program], Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014 and results were expressed as odds ratio for dichotomous variables and mean difference for continuous. p value ≤ 0.05 was considered significant. Trial sequential analysis (TSA) was performed using TSA version (Copenhagen: The Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016). PROSPERO trial registration number is CRD42017074673.


A total of 11 trials were included in the analysis, with a total of 1513 patients (751-LCBDE; 762-ERCP + LC). LCBDE was found to have significantly lower rates of technical failure [OR 0.59, 95% CI (0.38, 0.93), p = 0.02] and shorter hospital stay [MD − 1.63, 95% CI (− 3.23, − 0.03), p = 0.05]. There was no significant difference in mortality [OR 0.37, 95% CI (0.09, 1.51), p = 0.17], morbidity [OR 0.97, 95% CI (0.70, 1.33), p = 0.84], cost [MD − 379.13, 95% CI (− 784.80, 111.2), p = 0.13] or recurrent/retained stones [OR 1.01, 95% CI (0.38, 2.73), p = 0.98]. TSA showed that although the Z-curve crossed the boundaries of conventional significance, the estimated information size is yet to be achieved.


Single-stage LCBDE is superior to ERCP + LC in terms of technical success and shorter hospital stay in good-risk patients with gallstones and CBD stones, where expertise, operative time and instruments are available.


Laparoscopic common bile duct exploration LCBDE Endoscopic stone extraction ERCP with laparoscopic cholecystectomy Choledocholithiasis Meta-analysis 


Author contributions

RK, AN: conception and design of this work; acquisition and interpretation of data; drafting this work; and revising it critically for important intellectual content. Both authors also approve the manuscript in its current form for publication and agree to be accountable for all aspects of the work and to ensure that questions related to the accuracy or integrity of any part of this work will be appropriately investigated and resolved.

Compliance with ethical standards


Anand Narayan Singh and Ragini Kilambi have no conflict of interest or financial ties to disclose.

Supplementary material

464_2018_6170_MOESM1_ESM.docx (62 kb)
Supplementary material 1 (DOCX 61 KB)


  1. 1.
    Neuhaus H, Feussner H, Ungeheuer A, Hoffmann W, Siewert JR, Classen M (1992) Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy 24(9):745–749CrossRefPubMedGoogle Scholar
  2. 2.
    Wenckert A, Robertson B (1966) The natural course of gallstone disease: eleven-year review of 781 nonoperated cases. Gastroenterology 50(3):376–381PubMedGoogle Scholar
  3. 3.
    Bingener J, Schwesinger WH (2006) Management of common bile duct stones in a rural area of the United States: results of a survey. Surg Endosc 20(4):577–579CrossRefPubMedGoogle Scholar
  4. 4.
    Vannijvel M, Lesurtel M, Bouckaert W, Houben B, Knol J, Vangertruyden G et al (2016) A survey of European-African surgeons’ management of common bile duct stones. HPB 18(12):959–964CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Wandling MW, Hungness ES, Pavey ES, Stulberg JJ, Schwab B, Yang AD et al (2016) Nationwide assessment of trends in choledocholithiasis management in the United States from 1998 to 2013. JAMA Surg 151(12):1125–1130CrossRefPubMedGoogle Scholar
  6. 6.
    Alexakis N, Connor S (2012) Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones. HPB 14(4):254–259CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Dasari BVM, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L et al (2013) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 12(12):CD003327Google Scholar
  8. 8.
    Prasson P, Bai X, Zhang Q, Liang T (2016) One-stage laproendoscopic procedure versus two-stage procedure in the management for gallstone disease and biliary duct calculi: a systemic review and meta-analysis. Surg Endosc 30(8):3582–3590CrossRefPubMedGoogle Scholar
  9. 9.
    Lu J, Cheng Y, Xiong X-Z, Lin Y-X, Wu S-J, Cheng N-S (2012) Two-stage vs single-stage management for concomitant gallstones and common bile duct stones. World J Gastroenterol 18(24):3156–3166CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Nagaraja V, Eslick GD, Cox MR (2014) Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis. J Hepato-Biliary-Pancreat Sci 21(12):896–901CrossRefGoogle Scholar
  11. 11.
    Zhu H-Y, Xu M, Shen H-J, Yang C, Li F, Li K-W et al (2015) A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol 39(5):584–593CrossRefPubMedGoogle Scholar
  12. 12.
    Deeks J, Higgins J, Altman D (2011) Chapter 9: Analysing data and undertaking meta-analyses. In: Higgins JPT, Green S (eds) Cochrane Handbook for Systematic Reviews of Interventions Version 510 (updated March 2011) The Cochrane Collaboration.
  13. 13.
    Bansal VK, Misra MC, Garg P, Prabhu M (2010) A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones. Surg Endosc 24(8):1986–1989CrossRefPubMedGoogle Scholar
  14. 14.
    Bansal VK, Misra MC, Rajan K, Kilambi R, Kumar S, Krishna A et al (2014) Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc 28(3):875–885CrossRefPubMedGoogle Scholar
  15. 15.
    Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J et al (1999) E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13(10):952–957CrossRefPubMedGoogle Scholar
  16. 16.
    González JEB, Torres Peña R, Ruiz Torres J, Martínez Alfonso M, Brizuela Quintanilla R, Morera Pérez M (2016) Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open 4(11):E1188–E1193CrossRefGoogle Scholar
  17. 17.
    Ding G, Cai W, Qin M (2014) Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up. J Gastrointest Surg Off J Soc Surg Aliment Tract 18(5):947–951CrossRefGoogle Scholar
  18. 18.
    Ferulano GP, Dilillo S, D’Ambra M, Lionetti R, Silverio PD, Capasso S et al (2011) Laparoscopic one-stage vs endoscopic plus laparoscopic management of common Bile duct stones—a prospective randomized study. In: Iancu C (ed) Advances in endoscopic surgery. InTech. Available from:
  19. 19.
    Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A (2013) Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 206(4):457–463CrossRefPubMedGoogle Scholar
  20. 20.
    Noble H, Tranter S, Chesworth T, Norton S, Thompson M (2009) A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A 19(6):713–720CrossRefPubMedGoogle Scholar
  21. 21.
    Rogers SJ, Cello JP, Horn JK, Siperstein AE, Schecter WP, Campbell AR et al (2010) Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg 145(1):28–33CrossRefPubMedGoogle Scholar
  22. 22.
    Sgourakis G, Karaliotas K (2002) Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 57(4):467–474PubMedGoogle Scholar
  23. 23.
    Lv F, Zhang S, Ji M, Wang Y, Li P, Han W (2016) Single-stage management with combined tri-endoscopic approach for concomitant cholecystolithiasis and choledocholithiasis. Surg Endosc 30(12):5615–5620CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G et al (2017) Updated guideline on the management of common bile duct stones (CBDS). Gut 66(5):765–782CrossRefPubMedGoogle Scholar
  25. 25.
    Keeling NJ, Menzies D, Motson RW (1999) Laparoscopic exploration of the common bile duct: beyond the learning curve. Surg Endosc 13(2):109–112CrossRefPubMedGoogle Scholar
  26. 26.
    Baucom RB, Feurer ID, Shelton JS, Kummerow K, Holzman MD, Poulose BK (2016) Surgeons, ERCP, and laparoscopic common bile duct exploration: do we need a standard approach for common bile duct stones? Surg Endosc 30(2):414–423CrossRefPubMedGoogle Scholar
  27. 27.
    Christensen M, Matzen P, Schulze S, Rosenberg J (2004) Complications of ERCP: a prospective study. Gastrointest Endosc 60(5):721–731CrossRefPubMedGoogle Scholar
  28. 28.
    Donkervoort SC, van Ruler O, Dijksman LM, van Geloven AA, Pierik EG (2010) Identification of risk factors for an unfavorable laparoscopic cholecystectomy course after endoscopic retrograde cholangiography in the treatment of choledocholithiasis. Surg Endosc 24(4):798–804CrossRefPubMedGoogle Scholar
  29. 29.
    Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F et al (1998) Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 48(1):1–10CrossRefPubMedGoogle Scholar
  30. 30.
    Thompson MH, Tranter SE (2002) All-comers policy for laparoscopic exploration of the common bile duct. Br J Surg 89(12):1608–1612CrossRefPubMedGoogle Scholar
  31. 31.
    Wei Q, Wang J-G, Li L-B, Li J-D (2003) Management of choledocholithiasis: Comparison between laparoscopic common bile duct exploration and intraoperative endoscopic sphincterotomy. World J Gastroenterol WJG 9(12):2856–2858CrossRefPubMedGoogle Scholar
  32. 32.
    Tang CN, Tsui KK, Ha JPY, Siu WT, Li MKW (2006) Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single centre. Hong Kong Med J Xianggang Yi Xue Za Zhi 12(3):191–196PubMedGoogle Scholar
  33. 33.
    Ebner S, Rechner J, Beller S, Erhart K, Riegler FM, Szinicz G (2004) Laparoscopic management of common bile duct stones. Surg Endosc 18(5):762–765CrossRefPubMedGoogle Scholar
  34. 34.
    Li MKW, Tang CN, Lai ECH (2011) Managing concomitant gallbladder stones and common bile duct stones in the laparoscopic era: a systematic review. Asian J Endosc Surg 4(2):53–58CrossRefPubMedGoogle Scholar
  35. 35.
    Costi R, DiMauro D, Mazzeo A, Boselli AS, Contini S, Violi V et al (2007) Routine laparoscopic cholecystectomy after endoscopic sphincterotomy for choledocholithiasis in octogenarians: is it worth the risk? Surg Endosc 21(1):41–47CrossRefPubMedGoogle Scholar
  36. 36.
    Pring CM, Skelding-Millar L, Goodall RJR (2005) Expectant treatment or cholecystectomy after endoscopic retrograde cholangiopancreatography for choledocholithiasis in patients over 80 years old? Surg Endosc 19(3):357–360CrossRefPubMedGoogle Scholar
  37. 37.
    Lai J-H, Chen C-J, Chu C-H, Lin C-C, Sun F-J (2017) Cholecystectomy after sphincterotomy for preventing recurrence in elderly patients with acute cholangitis. Int J Gerontol.
  38. 38.
    Topal B, Vromman K, Aerts R, Verslype C, Van Steenbergen W, Penninckx F (2010) Hospital cost categories of one-stage versus two-stage management of common bile duct stones. Surg Endosc 24(2):413–416CrossRefPubMedGoogle Scholar
  39. 39.
    Heili MJ, Wintz NK, Fowler DL (1999) Choledocholithiasis: endoscopic versus laparoscopic management. Am Surg 65(2):135–138PubMedGoogle Scholar
  40. 40.
    Mattila A, Mrena J, Kellokumpu I (2017) Cost-analysis and effectiveness of one-stage laparoscopic versus two-stage endolaparoscopic management of cholecystocholedocholithiasis: a retrospective cohort study. BMC Surg 17(1):79CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Gastrointestinal Surgery and Liver TransplantationAll India Institute of Medical SciencesNew DelhiIndia
  2. 2.Department of HPB SurgeryInstitute of Liver and Biliary SciencesNew DelhiIndia

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