Meta-analysis of single-stage versus two-staged management for concomitant gallstones and common bile duct stones

J Minim Access Surg. Jul-Sep 2020;16(3):206-214. doi: 10.4103/jmas.JMAS_146_18.


Objective: The purpose of this article was to compare the effectiveness and safety of single-stage (laparoscopic cholecystectomy [LC] plus laparoscopic common bile duct exploration [LCBDE]) with two-stage (LC plus endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy [EST]) in management for concomitant gallstones and common bile duct (CBD) stones.

Materials and methods: Systematic review and meta-analysis of randomised controlled trials (RCTs) comparing outcomes following single-stage with two-stage management for concomitant gallstones and CBD stones published from 1990 to 2017 in PubMed, Embase and the Science Citation Index. The primary outcomes were stone clearance from the CBD, post-operative morbidity and mortality. The secondary outcomes were retained stone, conversion to other procedures, length of hospital stay and total operating time. Pooled risk ratio (RR) or weighted mean differences (WMD) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or random effects model.

Results: Eleven RCTs studies were included in this analysis. These studies included a total of 1338 patients: 666 underwent LC + LCBDE and 672 underwent LC + ERCP/EST. The meta-analysis showed that no significant difference was noted between the two groups regarding CBD stone clearance (RR: 1.06; 95% CI: 0.99-1.14; P= 0.12), post-operative morbidity (RR: 1.03; 95% CI: 0.79-1.34; P= 0.81), mortality (RR: 0.30; 95% CI: 0.06-1.41; P= 0.13), retained stone (RR: 0.91; 95% CI: 0.57-1.47; P= 0.71), conversion to other procedures (RR: 0.80; 95% CI: 0.55-0.16; P= 0.23), length of hospital stay (WMD: 1.24, 95% CI: 3.57-1.09, P= 0.30), total operating time (WMD: 25.42, 95% CI: 22.38-73.22, P= 0.30).

Conclusion: Single-stage is efficient and safe in the treatment of patients with concomitant gallstones and CBD stones while avoiding the second procedure. In selected patients, single-stage management for concomitant gallstones and CBD stones might be considered as the preferred approach. However, the findings have to be carefully interpreted due to the existence of heterogeneity, in addition, patient's condition, operator's experience also should be taken into account in making treatment decisions.

Keywords: Common bile duct stones; endoscopic retrograde cholangiopancreatography; endoscopic sphincterotomy; gallstones; laparoscopic cholecystectomy; laparoscopic common bile duct exploration; meta-analysis.