Skip to main content
SpringerLink
Log in

Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials

  • Review Article
  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

To update a 2018 meta-analysis on the comparative efficacy and safety of four surgical techniques in patients with concomitant gallstones and common bile duct (CBD) stones.

Methods

Randomized controlled trials (RCTs) comparing laparoscopic cholecystectomy (LC) plus laparoscopic common bile duct exploration (LCBDE), LC plus preoperative endoscopic retrograde cholangiopancreatography (PreERCP), LC plus intraoperative ERCP (IntraERCP), and LC plus postoperative ERCP (PostERCP) were included. Primary and secondary outcomes were compared using odds ratio, weighted mean difference, and 95% confidence intervals.

Results

Twenty-five RCTs involved 3145 patients were included. Of these, 1188 (37.8%) underwent LC + PreERCP, 1183 (37.6%) LC + LCBDE, 689 (21.9%) LC + IntraERCP, and 85 (2.7%) LC + PostERCP. This analysis demonstrated that LC plus IntraERCP was the most likely approach to achieve technical success and reduce morbidity. No significant differences were observed between the four treatments concerning major morbidity, mortality, and operative time. LC plus LCBDE was effective for increasing biliary leak and conversion as well as decreasing postoperative hemorrhage and total costs. Additionally, LC plus PreERCP was associated with higher postoperative pancreatitis, while LC plus IntraERCP was associated with a shorter length of hospital stay. There was significant heterogeneity in operative time, hospital stay, and total costs (τ2 > 1).

Conclusions

This analysis provides evidence that LC plus IntraERCP appears to be the optimal strategy for patients with concomitant gallstones and CBD stones owing to its advantage in technical success and morbidity. LC plus LCBDE is associated with higher biliary leak and lower postoperative hemorrhage, whereas LC plus PreERCP is associated with higher postoperative pancreatitis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. 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 66:765–782

    Article  PubMed  Google Scholar 

  2. Alexakis N, Connor S (2012) Meta-analysis of one- vs. two-stage laparoscopic/endoscopic management of common bile duct stones. HPB (Oxford) 14:254–259

    Article  PubMed  Google Scholar 

  3. Nagaraja V, Eslick GD, Cox MR (2014) Systematic review and meta-analysis of minimally invasive techniques for the management of cholecysto-choledocholithiasis. J Hepatob Pancreat Sci 21:896–901

    Article  Google Scholar 

  4. 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 30:3582–3590

    Article  PubMed  Google Scholar 

  5. Ricci C, Pagano N, Taffurelli G, Pacilio CA, Migliori M, Bazzoli F et al (2018) Comparison of efficacy and safety of 4 combinations of laparoscopic and intraoperative techniques for management of gallstone disease with biliary duct calculi: a systematic review and network meta-analysis. JAMA Surg 153:e181167

    Article  PubMed  PubMed Central  Google Scholar 

  6. Cuschieri A, Croce E, Faggioni A, Jakimowicz J, Lacy A, Lezoche E et al (1996) EAES ductal stone study. Preliminary findings of multi-center prospective randomized trial comparing two-stage vs. single-stage management. Surg Endosc 10:1130–1135

    Article  CAS  PubMed  Google Scholar 

  7. 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 28:875–885

    Article  PubMed  Google Scholar 

  8. Barreras González JE, Torres Peña R, Ruiz Torres J, Martínez Alfonso MÁ, Brizuela Quintanilla R, Morera Pérez M (2016) Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open 4:E1188–E1193

    Article  PubMed  PubMed Central  Google Scholar 

  9. Liu Z, Zhang L, Liu Y, Gu Y, Sun T (2017) Efficiency and safety of one-step procedure combined laparoscopic cholecystectomy and eretrograde cholangiopancreatography for treatment of cholecysto-choledocholithiasis: a randomized controlled trial. Am Surg 83:1263–1267

    Article  PubMed  Google Scholar 

  10. Zou Q, Ding Y, Li CS, Yang XP (2022) A randomized controlled trial of emergency LCBDE + LC and ERCP + LC in the treatment of choledocholithiasis with acute cholangitis. Wideochir Inne Tech Maloinwazyjne 17:156–162

    PubMed  Google Scholar 

  11. Hutton B, Salanti G, Caldwell DM, Chaimani A, Schmid CH, Cameron C et al (2015) The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations. Ann Intern Med 162:777–784

    Article  PubMed  Google Scholar 

  12. Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:13

    Article  PubMed  PubMed Central  Google Scholar 

  13. Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD et al (2011) The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928

    Article  PubMed  PubMed Central  Google Scholar 

  14. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD et al (2009) The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196

    Article  PubMed  Google Scholar 

  15. Higgins JP, Jackson D, Barrett JK, Lu G, Ades AE, White IR (2012) Consistency and inconsistency in network meta-analysis: concepts and models for multi-arm studies. Res Synth Methods 3:98–110

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Dias S, Welton NJ, Caldwell DM, Ades AE (2010) Checking consistency in mixed treatment comparison meta-analysis. Stat Med 29:932–944

    Article  CAS  PubMed  Google Scholar 

  17. Turner RM, Davey J, Clarke MJ, Thompson SG, Higgins JP (2012) Predicting the extent of heterogeneity in meta-analysis, using empirical data from the cochrane database of systematic reviews. Int J Epidemiol 41:818–827

    Article  PubMed  PubMed Central  Google Scholar 

  18. Chaimani A, Higgins JP, Mavridis D, Spyridonos P, Salanti G (2013) Graphical tools for network meta-analysis in STATA. PLoS ONE 8:e76654

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 351:159–161

    Article  CAS  PubMed  Google Scholar 

  20. Nathanson LK, O’Rourke NA, Martin IJ, Fielding GA, Cowen AE, Roberts RK et al (2005) Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 242:188–192

    Article  PubMed  PubMed Central  Google Scholar 

  21. 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 13:952–957

    Article  CAS  PubMed  Google Scholar 

  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 57:467–474

    CAS  PubMed  Google Scholar 

  23. 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 19:713–720

    Article  PubMed  Google Scholar 

  24. 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 24:1986–1989

    Article  PubMed  Google Scholar 

  25. 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 145:28–33

    Article  PubMed  Google Scholar 

  26. Ferulano GP, Dilillo S, D’Ambra M, Lionett 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, London, pp 291–306

  27. 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 206:457–463

    Article  PubMed  Google Scholar 

  28. 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 18:947–951

    Article  PubMed  Google Scholar 

  29. 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 30:5615–5620

    Article  PubMed  PubMed Central  Google Scholar 

  30. Hong DF, Xin Y, Chen DW (2006) Comparison of laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy and laparoscopic exploration of the common bile duct for cholecystocholedocholithiasis. Surg Endosc 20:424–427

    Article  PubMed  Google Scholar 

  31. ElGeidie AA, ElShobary MM, Naeem YM (2011) Laparoscopic exploration versus intraoperative endoscopic sphincterotomy for common bile duct stones: a prospective randomized trial. Dig Surg 28:424–431

    Article  PubMed  Google Scholar 

  32. Poh BR, Ho SP, Sritharan M, Yeong CC, Swan MP, Devonshire DA et al (2016) Randomized clinical trial of intraoperative endoscopic retrograde cholangiopancreatography versus laparoscopic bile duct exploration in patients with choledocholithiasis. Br J Surg 103:1117–1124

    Article  CAS  PubMed  Google Scholar 

  33. Lella F, Bagnolo F, Rebuffat C, Scalambra M, Bonassi U, Colombo E (2006) Use of the laparoscopic-endoscopic approach, the so-called “rendezvous” technique, in cholecystocholedocholithiasis: a valid method in cases with patient-related risk factors for post-ERCP pancreatitis. Surg Endosc 20:419–423

    Article  CAS  PubMed  Google Scholar 

  34. Morino M, Baracchi F, Miglietta C, Furlan N, Ragona R, Garbarini A (2006) Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg 244:889–893

    Article  PubMed  PubMed Central  Google Scholar 

  35. Rábago LR, Vicente C, Soler F, Delgado M, Moral I, Guerra I et al (2006) Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy 38:779–786

    Article  PubMed  Google Scholar 

  36. ElGeidie AA, ElEbidy GK, Naeem YM (2011) Preoperative versus intraoperative endoscopic sphincterotomy for management of common bile duct stones. Surg Endosc 25:1230–1237

    Article  PubMed  Google Scholar 

  37. Tzovaras G, Baloyiannis I, Zachari E, Symeonidis D, Zacharoulis D, Kapsoritakis A et al (2012) Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial. Ann Surg 255:435–439

    Article  PubMed  Google Scholar 

  38. Sahoo MR, Kumar AT, Patnaik A (2014) Randomised study on single stage laparo-endoscopic rendezvous (intra-operative ERCP) procedure versus two stage approach (Pre-operative ERCP followed by laparoscopic cholecystectomy) for the management of cholelithiasis with choledocholithiasis. J Minim Access Surg 10:139–143

    Article  PubMed  PubMed Central  Google Scholar 

  39. Lopez-Lopez V, Gil-Vazquez PJ, Ferreras D, Nassar AHM, Bansal VK, Topal B et al (2022) Multi-institutional expert update on the use of laparoscopic bile duct exploration in the management of choledocholithiasis: lesson learned from 3950 procedures. J Hepatobiliary Pancreat Sci. https://doi.org/10.1002/jhbp.1123

    Article  PubMed  Google Scholar 

  40. 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 (Oxford) 18:959–964

    Article  PubMed  Google Scholar 

  41. Jorba R, Pavel MC, Llàcer-Millán E, Estalella L, Achalandabaso M, Julià-Verdaguer E et al (2021) Contemporary management of concomitant gallstones and common bile duct stones: a survey of Spanish surgeons. Surg Endosc 35:5024–5033

    Article  PubMed  Google Scholar 

  42. Tanase A, Dhanda A, Cramp M, Streeter A, Aroori S (2022) A UK survey on variation in the practice of management of choledocholithiasis and laparoscopic common bile duct exploration (ALiCE survey). Surg Endosc. https://doi.org/10.1007/s00464-021-08983-0

    Article  PubMed  Google Scholar 

  43. Paik KY, Kim EK (2013) Laparoscopic common bile duct exploration after unsuccessful endoscopic stone removal. J Laparoendosc Adv Surg Tech A 23:137–140

    Article  PubMed  Google Scholar 

  44. Freeman ML, DiSario JA, Nelson DB, Fennerty MB, Lee JG, Bjorkman DJ et al (2001) Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc 54:425–434

    Article  CAS  PubMed  Google Scholar 

  45. Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J et al (2006) Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 101:139–147

    Article  PubMed  Google Scholar 

  46. De Vries A, Donkervoort SC, van Geloven AA, Pierik EG (2005) Conversion rate of laparoscopic cholecystectomy after endoscopic retrograde cholangiography in the treatment of choledocholithiasis: Does the time interval matter? Surg Endosc 19:996–1001

    Article  PubMed  Google Scholar 

  47. Reinders JS, Gouma DJ, Ubbink DT, van Ramshorst B, Boerma D (2014) Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis: a systematic review. World J Surg 38:2403–2411

    Article  PubMed  Google Scholar 

  48. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G et al (2020) ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 52:127–149

    Article  PubMed  Google Scholar 

  49. Williams EJ, Taylor S, Fairclough P, Hamlyn A, Logan RF, Martin D et al (2007) Risk factors for complication following ERCP: results of a large-scale, prospective multicenter study. Endoscopy 39:793–801

    Article  CAS  PubMed  Google Scholar 

  50. Wang P, Li ZS, Liu F, Ren X, Lu NH, Fan ZN et al (2009) Risk factors for ERCP-related complications: a prospective multicenter study. Am J Gastroenterol 104:31–40

    Article  PubMed  Google Scholar 

  51. Halttunen J, Meisner S, Aabakken L, Arnelo U, Grönroos J, Hauge T et al (2014) Difficult cannulation as defined by a prospective study of the Scandinavian Association for Digestive Endoscopy (SADE) in 907 ERCPs. Scand J Gastroenterol 49:752–758

    Article  PubMed  Google Scholar 

  52. Lee HJ, Cho CM, Heo J, Jung MK, Kim TN, Kim KH et al (2020) Impact of hospital volume and the experience of endoscopist on adverse events related to endoscopic retrograde cholangiopancreatography: a prospective observational study. Gut Liver 14:257–264

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Funding

None.

Author information

Author notes

  1. Jisheng Zhu and Guiyan Wang have contributed equally to this work.

Authors and Affiliations

  1. Department of General Surgery, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China

    Jisheng Zhu, Bin Xie, Weidong Xiao & Yong Li

  2. Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China

    Guiyan Wang

  3. Department of Burn, The First Affiliated Hospital of Nanchang University, No. 17 Yongwai Zhengjie, Nanchang, 330006, Jiangxi, China

    Zhengying Jiang

Authors
  1. Jisheng Zhu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Guiyan Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bin Xie
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Zhengying Jiang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Weidong Xiao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Yong Li
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Yong Li.

Ethics declarations

Disclosures

Drs. Jisheng Zhu, Guiyan Wang, Bin Xie, Zhengying Jiang, Weidong Xiao, and Yong Li have no conflict of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file 1 (DOC 3770 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhu, J., Wang, G., Xie, B. et al. Minimally invasive management of concomitant gallstones and common bile duct stones: an updated network meta-analysis of randomized controlled trials. Surg Endosc 37, 1683–1693 (2023). https://doi.org/10.1007/s00464-022-09723-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-022-09723-8

Keywords

Search

Navigation