Prevalence and Predictors of Unnecessary Endoscopic Retrograde Cholangiopancreatography in the Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy

  • Hyun Woo Lee
  • Do Hyun ParkEmail author
  • Jae Hoon Lee
  • Dong Wook Oh
  • Tae Jun Song
  • Sang Soo Lee
  • Dong-Wan Seo
  • Sung Koo Lee
  • Myung-Hwan Kim
  • Ji Eun Moon
Original Article



A two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP), followed by cholecystectomy, is one of the primary treatments of concomitant gallstones and choledocholithiasis. However, negative findings on ERCP and migrating gallstones after cholecystectomy are major concerns. This study aimed to identify the prevalence of unnecessary ERCP and to develop and validate a predictive nomogram using preoperative factors in patients who underwent a two-stage procedure.


Consecutive 931 patients were treated with the two-stage procedure for evident gallstones and suspected choledocholithiasis. After the cholecystectomy, a cholangiogram was performed to confirm the absence of the migrating gallstones. The patients were divided into derivation (n = 652) and validation (n = 279) cohorts.


A total of 26.5% (247/931) patients had unnecessary ERCP (negative choledocholithiasis, 14.6%; migrating gallstones, 11.9%). No stones on images (P < 0.001), total bilirubin < 1.2 mg/dL (P = 0.006), and common bile duct diameter < 8.0 mm (P = 0.004) were independent factors associated with negative finding on ERCP with a validated nomogram area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.64–0.80). For migrating gallstones after cholecystectomy, radiolucent gallstones (P < 0.001), gallstone size ≤ 6.4 mm (P = 0.001), cystic duct stones (P < 0.001), gallbladder wall thickness ≥ 3.2 mm (P = 0.003), and low-lying cystic duct (P < 0.001) were independent factors with a validated nomogram AUC of 0.77 (95% CI 0.68–0.87).


About one fourth of the patients may have unnecessary ERCP in the two-stage procedure. Based on our nomogram using preoperative factors, high-risk patients who are more likely to perform unnecessary ERCP could be considered for the one-stage procedure.


Endoscopic retrograde cholangiopancreatography Cholecystectomy Gallstones Choledocholithiasis Two-stage procedure 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Supplementary material

11605_2018_4090_Fig3_ESM.png (128 kb)
Supplementary Figure 1

The flow protocol of the study. ERCP, endoscopic retrograde cholangiopancreatography; ENBD, endoscopic nasobiliary drainage; CBD, common bile duct (PNG 127 kb)

11605_2018_4090_MOESM1_ESM.tif (1.3 mb)
High Resolution Image (TIF 1308 kb)
11605_2018_4090_Fig4_ESM.png (1.1 mb)
Supplementary Figure 2

Nomogram to predict (A) negative choledocholithiasis on ERCP and (B) migrating gallstones after two-stage procedure. CBD, common bile duct; GB, gallbladder (PNG 1156 kb)

11605_2018_4090_MOESM3_ESM.tif (2.2 mb)
High Resolution Image (TIF 2288 kb)
11605_2018_4090_Fig5_ESM.png (1.2 mb)
Supplementary Figure 3

(PNG 1208 kb)

11605_2018_4090_MOESM2_ESM.tif (2 mb)
High Resolution Image (TIF 2073 kb)
11605_2018_4090_MOESM4_ESM.docx (20 kb)
ESM 4 (DOCX 19 kb)


  1. 1.
    Ko CW, Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc 2002; 56: S165–169.CrossRefGoogle Scholar
  2. 2.
    Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis. Br J Surg 2005; 92: 1241–1247.CrossRefGoogle Scholar
  3. 3.
    Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20: 1075–1083.CrossRefGoogle Scholar
  4. 4.
    Lee A, Min SK, Park JJ, Lee HK. Laparoscopic common bile duct exploration for elderly patients: as a first treatment strategy for common bile duct stones. J Korean Surg Soc 2011; 81: 128–133.CrossRefGoogle Scholar
  5. 5.
    Riciardi R, Islam S, Canete JJ, Arcand PL, Stoker ME. Effectiveness and long-term results of laparoscopic common bile duct exploration. Surg Endosc 2003; 17: 19–22.CrossRefGoogle Scholar
  6. 6.
    Fitzgibbons RJ, Jr., Gardner GC. Laparoscopic surgery and the common bile duct. World J Surg 2001; 25: 1317–1324.CrossRefGoogle Scholar
  7. 7.
    Wandling MW, Hungness ES, Pavey ES, Stulberg JJ, Schwab B, Yang AD et al. Nationwide Assessment of Trends in Choledocholithiasis Management in the United States From 1998 to 2013. JAMA Surg 2016; 151: 1125–1130.CrossRefGoogle Scholar
  8. 8.
    Rhodes M, Sussman L, Cohen L, Lewis MP. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998; 351: 159–161.CrossRefGoogle Scholar
  9. 9.
    Zhu HY, Xu M, Shen HJ, Yang C, Li F, Li KW et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol 2015; 39: 584–593.CrossRefGoogle Scholar
  10. 10.
    Oria A, Alvarez J, Chiappetta L, Spina JC, Hernandez N, Iovaldi M et al. Choledocholithiasis in acute gallstone pancreatitis. Incidence and clinical significance. Arch Surg 1991; 126: 566–568.CrossRefGoogle Scholar
  11. 11.
    Kohut M, Nowakowska-Dulawa E, Marek T, Kaczor R, Nowak A. Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones. Endoscopy 2002; 34:299–303.CrossRefGoogle Scholar
  12. 12.
    Adams MA, Hosmer AE, Wamsteker EJ, Anderson MA, Elta GH, Kubiliun NM et al. Predicting the likelihood of a persistent bile duct stone in patients with suspected choledocholithiasis: accuracy of existing guidelines and the impact of laboratory trends. Gastrointest Endosc 2015; 82: 88–93.CrossRefGoogle Scholar
  13. 13.
    Trotman BW, Soloway RD. Pigment gallstone disease: Summary of the National Institutes of Health--international workshop. Hepatology 1982; 2: 879–884.CrossRefGoogle Scholar
  14. 14.
    Kim IS, Myung SJ, Lee SS, Lee SK, Kim MH. Classification and nomenclature of gallstones revisited. Yonsei Med J 2003; 44: 561–570.CrossRefGoogle Scholar
  15. 15.
    Ding G, Cai W, Qin M. 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 2014; 18: 947–951.CrossRefGoogle Scholar
  16. 16.
    Lu J, Cheng Y, Xiong XZ, Lin YX, Wu SJ, Cheng NS. Two-stage vs single-stage management for concomitant gallstones and common bile duct stones. World J Gastroenterol 2012; 18: 3156–3166.CrossRefGoogle Scholar
  17. 17.
    Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71: 1–9.CrossRefGoogle Scholar
  18. 18.
    He H, Tan C, Wu J, Dai N, Hu W, Zhang Y et al. Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones. Gastrointest Endosc 2017; 86: 525–532.CrossRefGoogle Scholar
  19. 19.
    Narvaez Rivera RM, Gonzalez Gonzalez JA, Monreal Robles R, Garcia Compean D, Paz Delgadillo J, Garza Galindo AA et al. Accuracy of ASGE criteria for the prediction of choledocholithiasis. Rev Esp Enferm Dig 2016; 108: 309–314.CrossRefGoogle Scholar
  20. 20.
    Ebrahim M, Sorensen LT, Jorgensen LN, Kalaitzakis E. Current clinical algorithms for predicting common bile duct stones have only moderate accuracy. Dig Endosc 2018; 30: 477–484CrossRefGoogle Scholar
  21. 21.
    Sethi S, Wang F, Korson AS, Krishnan S, Berzin TM, Chuttani R et al. Prospective assessment of consensus criteria for evaluation of patients with suspected choledocholithiasis. Dig Endosc 2016; 28: 75–82.CrossRefGoogle Scholar
  22. 22.
    Garrow D, Miller S, Sinha D, Conway J, Hoffman BJ, Hawes RH et al. Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007; 5: 616–623.CrossRefGoogle Scholar
  23. 23.
    Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008; 67: 235–244.CrossRefGoogle Scholar
  24. 24.
    Prachayakul V, Aswakul P, Bhunthumkomol P, Deesomsak M. Diagnostic yield of endoscopic ultrasonography in patients with intermediate or high likelihood of choledocholithiasis: a retrospective study from one university-based endoscopy center. BMC Gastroenterol 2014; 14: 165.CrossRefGoogle Scholar
  25. 25.
    Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell T. Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 2003; 289: 1639–1644.CrossRefGoogle Scholar
  26. 26.
    Pierce RA, Jonnalagadda S, Spitler JA, Tessier DJ, Liaw JM, Lall SC et al. Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP. Surg Endosc 2008; 22: 2365–2372.CrossRefGoogle Scholar
  27. 27.
    Bansal VK, Misra MC, Garg P, Prabhu M. A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones. Surg Endosc 2010; 24: 1986–1989.CrossRefGoogle Scholar
  28. 28.
    Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 2013; 206: 457–463.CrossRefGoogle Scholar
  29. 29.
    Prasson P, Bai X, Zhang Q, Liang T. 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 2016; 30: 3582–3590.CrossRefGoogle Scholar
  30. 30.
    Iranmanesh P, Frossard JL, Mugnier-Konrad B, Morel P, Majno P, Nguyen-Tang T et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial. JAMA 2014; 312: 137–144.CrossRefGoogle Scholar
  31. 31.
    Enochsson L, Lindberg B, Swahn F, Arnelo U. Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience. Surg Endosc 2004; 18: 367–371.CrossRefGoogle Scholar
  32. 32.
    Bencini L, Tommasi C, Manetti R, Farsi M. Modern approach to cholecysto-choledocholithiasis. World J Gastrointest Endosc 2014; 6: 32–40.CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Hyun Woo Lee
    • 1
  • Do Hyun Park
    • 2
    Email author
  • Jae Hoon Lee
    • 3
  • Dong Wook Oh
    • 2
  • Tae Jun Song
    • 2
  • Sang Soo Lee
    • 2
  • Dong-Wan Seo
    • 2
  • Sung Koo Lee
    • 2
  • Myung-Hwan Kim
    • 2
  • Ji Eun Moon
    • 4
  1. 1.Digestive Disease Center and Research Institute, Department of Internal MedicineSoonchunhyang University school of MedicineBucheonSouth Korea
  2. 2.Division of Gastroenterology, Department of Internal MedicineUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
  3. 3.Division of Hepatobiliary and Pancreatic Surgery, Department of SurgeryUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
  4. 4.Department of Biostatistics, Clinical Trial CenterSoonchunhyang University Bucheon HospitalBucheonSouth Korea

Personalised recommendations