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
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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 0.9.5.5 (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.
KeywordsLaparoscopic common bile duct exploration LCBDE Endoscopic stone extraction ERCP with laparoscopic cholecystectomy Choledocholithiasis Meta-analysis
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.
- 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
- 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. http://www.cochrane-handbook.org
- 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
- 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: http://www.intechopen.com/books/advances-in-endoscopic-surgery/laparoscopic-one-stage-vs-endoscopic-plus-laparoscopic-management-of-common-bile-duct-stones-a-prosp
- 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.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
- 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. http://www.sciencedirect.com/science/article/pii/S1873959817302156