Common bile duct stones management: A network meta-analysis

Reclaim the duct! Laparoscopic common bile duct exploration for the acute care surgeon

Laparoscopic common bile duct exploration (LCBDE) has emerged as a viable and effective alternative to the traditional multistage management of choledocholithiasis involving preoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP). Despite its advantages, LCBDE remains underused, particularly among trauma and acute care surgeons, due to its technical challenges and limited training opportunities. This practical review examines advancements in LCBDE technology, exploring its clinical applications, outlining key steps for its successful implementation, and evaluating selected current literature. Multiple studies have demonstrated that LCBDE achieves comparable success rates to ERCP and reduces hospital length of stay, overall costs, and the need for additional procedures. However, barriers to widespread adoption persist, primarily related to the technical learning curve, limited exposure during surgical training, and institutional workflow constraints favoring ERCP. With recent advancements in surgical technology and enhanced training models, LCBDE is becoming increasingly adoptable. Given their frequent management of biliary abnormality, trauma and acute care surgeons should develop proficiency in this technique to optimize patient outcomes and minimizing procedural burden.

Meta-analysis of randomized controlled trials comparing single-stage laparoscopic versus two-stage endoscopic management followed by laparoscopic cholecystectomy of preoperatively diagnosed common bile duct stones

BACKGROUND

Common bile duct stones are a significant public health issue that often requires surgical intervention. Two primary surgical techniques for addressing these conditions are laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) in 1 or 2 stages, respectively. This systematic review and meta-analysis compared the efficacy and results of these 2 techniques.

METHODS

A systematic review and meta-analysis of randomized clinical trials followed the PRISMA and AMSTAR 2 guidelines. Literature research were performed in the Cochrane Library, PubMed/MEDLINE, Embase, and Google Scholar up to March 1, 2023.

RESULTS

Fourteen studies with a total of 1849 patients were included. The success rate was similar between LCBDE (872/919 patients) and ERCP followed by LC (866/930 patients) (odds ratio [OR] = 1.31; 95% confidence interval [CI] [0.76, 2.25], P = .33). There was no significant difference in residual stones (OR = 0.71; 95% CI [0.28, 1.83], P = .48), mortality (OR = 0.55; 95% CI [0.14, 2.14], P = .39), morbidity (OR = 0.87; 95% CI [0.66, 1.16], P = .36) or hospital stay (mean difference = -1.31; 95% CI [-2.89, 0.26], P = .10) between the 2 groups. Meta-analysis found no significant differences between LCBDE and ERCP followed by LC in terms of success rate, residual stones, mortality, morbidity or hospital stay.

CONCLUSION

Both techniques are viable options for the treatment of choledocholithiasis and gallbladder stones. More multicentric randomized controlled trials are recommended to confirm these findings and explore long-term outcomes.

Lessons learned from implementing laparoscopic common bile duct exploration at a safety net hospital

BACKGROUND

Mounting evidence favors one-stage laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography with cholecystectomy for choledocholithiasis. However, laparoscopic cholecystectomy with common bile duct exploration remains underused. In 2020, our center initiated a laparoscopic cholecystectomy with common bile duct exploration program for choledocholithiasis. This study compares the experience and outcomes of laparoscopic cholecystectomy with common bile duct exploration compared with endoscopic retrograde cholangiopancreatography with cholecystectomy at a safety net hospital.

METHODS

This single-center, retrospective study analyzed data from 179 patients admitted with choledocholithiasis from 2019 to 2023. Demographics, preoperative investigations, intraoperative details, and postoperative outcomes were evaluated.

RESULTS

The study included 179 patients (55.6 ± 21.0 years, 66% female) with American Society of Anesthesiologists Physical Status Classification System score III (II-III) and body mass index 29 kg/m2 (25.8-35.5 kg/m2). Of these, 148 underwent endoscopic retrograde cholangiopancreatography with cholecystectomy and 31 underwent laparoscopic cholecystectomy with common bile duct exploration. Demographic and preoperative data were similar between groups. Laparoscopic cholecystectomy with common bile duct exploration achieved a 74.2% success rate. Laparoscopic cholecystectomy with common bile duct exploration's average operative time was 180 (139-213) minutes, with a 3.2% postoperative bile leak and 35.4% requiring postoperative ERCP. Median lengths of stay were 3 (1-4) for laparoscopic cholecystectomy with common bile duct exploration and 4 days (3-7) for endoscopic retrograde cholangiopancreatography with cholecystectomy (Z = -3.16, P = .002). The number of readmissions were 1.2 ± 0.4 for laparoscopic cholecystectomy with common bile duct exploration and 1.9 ± 1.3 for endoscopic retrograde cholangiopancreatography with cholecystectomy (t = 1.43, P = .08). Additional procedures for choledocholithiasis were performed in 36% of laparoscopic cholecystectomy with common bile duct exploration and 79% of ERCP + LC cases (χ2 = 21.7, P < .0001).

CONCLUSION

The study highlights challenges in implementing laparoscopic cholecystectomy with common bile duct exploration at a safety net hospital. Results support laparoscopic cholecystectomy with common bile duct exploration over endoscopic retrograde cholangiopancreatography, with cholecystectomy, with shorter stays, fewer readmissions, and fewer additional procedures reported. Laparoscopic cholecystectomy with common bile duct exploration remains underused, with only 17.3% of patients who underwent one-stage laparoscopic cholecystectomy with common bile duct exploration. Further research is needed for laparoscopic cholecystectomy with common bile duct exploration's expansion as the superior choledocholithiasis treatment.

Laparoscopic common bile duct exploration for choledocholithiasis on an emergency setting

INTRODUCTION

Choledocholithiasis is a common clinical condition that may present with severe complications such as acute cholecystitis or cholangitis, requiring treatment on an emergency setting. This situation is frequently managed following an endoscopic approach by ERCP. However, access to emergent endoscopic biliary decompression is lacking in most centers. In addition, experience in laparoscopic common bile duct exploration (LCBDE) in elective patients is increasing revealing good outcomes. This study analyzes the outcomes of LCBDE management of choledocholithiasis performed on an emergency setting (ELCBDE).

MATERIALS AND METHODS

We performed a descriptive, prospective, single-center study of patients undergoing ELCBDE from January 2020 to December 2023. Demographic, clinical, and surgical variables were recorded. Postoperative complications (Dindo-Clavien), the success of stone clearance, and the occurrence of bile leaks (ISGLS) were also documented. Recurrence of choledocholithiasis and the association between severe complications and Charlson Comorbidity Index (CCI) were analyzed.

RESULTS

A total of 31 patients were included. Median age was of 78 years. The transductal (TD) approach was employed in all cases without conversion to open surgery. The median CCI was 4. Intraoperative cholangiography was performed in 19.4% of cases and over 4 stones were extracted in 35.5% of the patients. Primary closure of the choledochotomy was achieved in 93.5% of patients. Severe complications (DindoClavien ≥ 3) occurred in 6.5% of patients. There were no reintervention or technique related deaths. Stone recurrence was not detected. The mean hospital stay was 4 days. Neither CCI nor advanced age was significantly associated with severe complications development (p > 0.05).

CONCLUSIONS

ELCBDE plus LC is an effective and safe procedure associated with low morbidity and mortality rates. Patients with a high CCI or advanced age should not be discarded for emergent laparoscopic approach. Our results support the choice of ELCBDE as a primary option in the emergency management of choledocholithiasis.

Endoscopic Papillary Large Balloon Dilatation With or Without Endoscopic Sphincterotomy in the Treatment of Common Bile Duct Stones

PURPOSE OF REVIEW

Endoscopic papillary large balloon dilation (EPLBD) has been proved to have better efficacy and safety in removing common bile duct stones. Conventional endoscopic sphincterotomy (EST) is usually performed before EPLBD. However, EPLBD without EST has recently reported short-term outcomes similar to those of EPLBD with EST. This article summarizes the latest research advances in EPLBD with or without EST for the treatment of large common bile duct stones (CBDS) as a way to provide further evidence to support the ERCP surgeon's choice of which technique to use for the treatment of large CBDS.

FINDINGS

EPLBD alone is recommended in cases of anatomical abnormalities or bleeding tendencies. EPLBD with EST is recommended in patients with stenosis of the duodenal papilla or distal common bile duct or with periportal diverticula. Most clinical studies have shown that the clinical efficacy and incidence of adverse events associated with ESLBD are comparable to those of standalone EPLBD. However, further large-scale prospective randomized controlled trials are needed to confirm these findings.

Comparative efficacy and safety of 3 endoscopic techniques for the treatment of large common bile duct stones (≥15 mm): long-term follow-up

BACKGROUND AND AIMS

The effectiveness of endoscopic papillary large balloon dilation (EPLBD) alone versus EPLBD combined with endoscopic sphincterotomy (EST) in treating large common bile duct stones (CBDSs; ≥15 mm) remains unclear. This study aimed to evaluate the safety and treatment outcomes of EPLBD combined with limited or large EST versus EPLBD alone in removing large CBDSs.

METHODS

Between January 2013 and September 2024, total of 408 patients underwent EPLBD, either alone or in combination with EST, to treat large CBDSs (≥15 mm). Patients were divided into 3 groups: EPLBD alone (n = 92), EPLBD with limited EST (n = 124), and EPLBD with large EST (n = 192). The study compared the first-session stone clearance rate, overall stone success rate, mechanical lithotripsy use, and adverse event rate.

RESULTS

Compared with the EPLBD alone group, the EPLBD with limited EST and the EPLBD with large EST groups exhibited higher initial stone clearance rates, required fewer endoscopic procedures for complete stone removal, and had lower rates of mechanical lithotripsy use and CBDS recurrence. Compared with the EPLBD with limited EST group, the EPLBD with large EST group showed a higher initial stone clearance rate, fewer endoscopic procedures required for complete CBDS removal, and no significant differences in adverse events. The multivariate analysis showed that the endoscopic technique and number of endoscopic operations were strongly associated with CBDS recurrence.

CONCLUSIONS

EPLBD combined with large EST may represent a more rational endoscopic technique for treating large CBDSs.

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrence-associated risk factors

BACKGROUND

There remain controversies regarding the surgical treatment of extrahepatic bile duct stones (EHBDSs) in clinical practice.

AIM

To explore the curative effect of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE) for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.

METHODS

Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected. Among them, patients treated with open choledocholithotomy plus LC or open cholecystectomy (OC) were set as the control group (n = 40), and those treated with LC plus CBDE served as the observation group (n = 42). The surgical outcomes of the two groups were compared, the surgical complications and Gastrointestinal Quality of Life Index (GIQLI) scores were counted, and the one-year prognostic recurrence was recorded. Independent factors for postoperative recurrence were determined using univariate and multivariate analyses.

RESULTS

The two groups were comparable in the stone residual rate (P > 0.05). The operation time (P < 0.05), intraoperative bleeding (P < 0.05), and total complication rate (P = 0.005) were lower in the observation group than in the control group. The observation group exhibited a marked increase in the GIQLI score, which was higher than the control group (P < 0.05). A lower one-year recurrence rate was determined in the observation group vs the control group (P = 0.027). Sphincter of Oddi dysfunction [odds ratio (OR) = 5.712, P = 0.007] and the treatment scheme of open choledocholithotomy plus LC or OC (OR = 6.771, P = 0.008) were the independent risk factors for one-year recurrence in patients after surgery.

CONCLUSION

LC plus CBDE for patients with EHBDSs can reduce stone residuals, intraoperative bleeding, complications, and postoperative recurrence.

Comparative efficacy of laparoscopic choledocholithotomy with T-tube insertion vs. primary suture in the management of cholecystolithiasis complicated by choledocholithiasis

OBJECTIVE

To evaluate the efficacy of laparoscopic choledocholithotomy with either an indwelling T-tube or primary suture in treating cholecystolithiasis complicated by choledocholithiasis.

METHODS

We conducted a retrospective analysis of 133 patients with cholecystolithiasis complicated by choledocholithiasis treated at Inner Mongolia Aerospace Medical Baogang Hospital from March 2020 to March 2023. Patients were divided into a control group (laparoscopic choledocholithotomy with T-tube placement) and an observation group (laparoscopic choledocholithotomy with primary suture). We compared general and surgery-related data between groups. Factors correlated with favorable postoperative outcomes were identified using univariate and multivariate logistic regression analyses.

RESULTS

The observation group exhibited significantly shorter surgical times, faster intestinal function recovery, reduced postoperative hospital stays, and lower total hospitalization costs compared to the control group (all P < 0.05). No significant differences were observed in postoperative total bilirubin (TBIL), aspartate aminotransferase (AST), or alanine aminotransferase (ALT) levels between the groups (all P > 0.05). Both primary suture technique and the absence of postoperative complications were independent predictors of favorable outcomes.

CONCLUSION

Laparoscopic choledocholithotomy with primary suture is associated with shorter operation times, reduced medical costs, decreased hospitalization duration, and quicker gastrointestinal recovery compared to the traditional T-tube approach. This method is safe and feasible, provided clinicians are well-versed in its indications.

Assessment of The Factors Related to The Spontaneous Passage of Common Bile Duct Stones

Background: Common bile duct (CBD) stones may pass spontaneously without any intervention. Assessment of the predictors of spontaneous passage can contribute to avoiding unnecessary endoscopic retrograde cholangiopancreatography (ERCP) implementation. This study aimed to investigate the factors related to spontaneous passage of CBD stones. Methods: From January 2021 to August 2023, patients with naïve papilla who had undergone biliary ERCP and with CBD stones detected by MRCP before the procedure were analyzed retrospectively. Subjects were divided into two groups on the basis of the presence of stones during the ERCP procedure: the spontaneous passage group and the non-passage group. Groups were compared in terms of demographic, laboratory, and radiological data. Results: A total of 236 patients, including 26 in the spontaneous passage group and 210 in the non-passage group, were involved. Multivariate logistic regression analyses revealed that only stone size was significantly associated with spontaneous passage. From ROC curve analysis, stone size with a cut-off value of 4.3 mm predicted spontaneous passage with 58% sensitivity and 85% specificity. Conclusions: Stones with a size of less than 4.3 mm are more likely to pass spontaneously without endoscopic intervention. Paying attention to the stone diameter before ERCP procedures can contribute to avoiding unnecessary ERCP implementation.

Contemporary management of common bile duct stone: What you need to know

ABSTRACT

Choledocholithiasis is a common presentation of symptomatic cholelithiasis encountered by the acute care surgeon. There is a wide spectrum of variation in management of this disease due to evolutions in laparoscopic and endoscopic techniques. Intricacies in management are related to the timing of diagnosis as well as locally available imaging modalities, surgical expertise, and ancillary advanced endoscopy and interventional radiological support. While individual patient demographics and institutional characteristics will determine management of choledocholithiasis, it is incumbent for the treating surgeon to be well versed in all manners of therapy currently available. The objective of this review is to provide an evidence-based summary of the contemporary management of choledocholithiasis.

Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy?

INTRODUCTION

Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy.

METHODS

A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against.

RESULTS

From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC.

CONCLUSIONS

In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.

Laparoscopic transcystic common bile duct exploration versus transgastric endoscopic retrograde cholangiography during cholecystectomy after Roux-en-Y gastric bypass

BACKGROUND

Treatment of common bile duct (CBD) stones after Roux-en-Y gastric bypass (RYGB) poses a particular challenge given the altered anatomy and inability to perform a standard endoscopic retrograde cholangiogram (ERC). The optimal treatment strategy for intraoperatively encountered CBD stones in post-RYGB patients has not been established.

OBJECTIVES

To compare outcomes following laparoscopic transcystic common bile duct exploration (LTCBDE) and laparoscopy-assisted transgastric ERC for CBDs during cholecystectomy in RYGB-operated patients.

SETTING

Swedish nationwide multi-registry study.

METHODS

The Swedish Registry for Gallstone Surgery and ERCs, GallRiks (n = 215,670), and the Scandinavian Obesity Surgery Registry (SOReg) (n = 60,479) were cross-matched for cholecystectomies with intraoperatively encountered CBD stones in patients with previous RYGB surgery between 2011 and 2020.

RESULTS

Registry cross-matching found 550 patients. Both LTCBDE (n = 132) and transgastric ERC (n = 145) were comparable in terms of low rates of intraoperative adverse events (1% versus 2%) and postoperative adverse events within 30 days (16% versus 18%). LTCBDE required significantly shorter operating time (P = .005) by on average 31 minutes, 95% confidence interval (CI) [10.3-52.6], and was more often used for smaller stones <4 mm in size (30% versus 17%, P = .010). However, transgastric ERC was more often used in acute surgery (78% versus 63%, P = .006) and for larger stones >8 mm in size (25% versus 8%, P < .001).

CONCLUSIONS

LTCBDE and transgastric ERC have similarly low complication rates for clearance of intraoperatively encountered CBD stones in RYGB-operated patients, but LTCBDE is faster while transgastric ERC is more often used in conjunction with larger bile duct stones.

Current management of concomitant cholelithiasis and common bile duct stones

The management policy of concomitant cholelithiasis and choledocholithiasis is based on a one- or two-stage procedure. It basically includes either laparoscopic cholecystectomy (LC) with laparoscopic common bile duct (CBD) exploration (LCBDE) in the same operation or LC with preoperative, postoperative and even intraoperative endoscopic retrograde cholangiopancreatography-endoscopic sphincterotomy (ERCP-ES) for stone clearance. The most frequently used worldwide option is preoperative ERCP-ES and stone removal followed by LC, preferably on the next day. In cases where preoperative ERCP-ES is not feasible, the proposed alternative of intraoperative rendezvous ERCP-ES simultaneously with LC has been advocated. The intraoperative extraction of CBD stones is superior to postoperative rendezvous ERCP-ES. However, there is no consensus on the superiority of laparoendoscopic rendezvous. This is equivalent to a traditional two-stage procedure. Endoscopic papillary large balloon dilation reduces recurrence. LCBDE and intraoperative ERCP have similar good outcomes. The risk of recurrence after ERCP-ES is greater than that after LCBDE. Laparoscopic ultrasonography may delineate the anatomy and detect CBD stones. The majority of surgeons prefer the transcductal instead of the transcystic approach for CBDE with or without T-tube drainage, but the transcystic approach must be used where possible. LCBDE is a safe and effective choice when performed by an experienced surgeon. However, the requirement of specific equipment and advanced training are drawbacks. The percutaneous approach is an alternative when ERCP fails. Surgical or endoscopic reintervention for retained stones may be needed. For asymptomatic CBD stones, ERCP clearance is the first-choice method. Both one-stage and two-stage management are acceptable and can ensure improved quality of life.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

BACKGROUND

In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay.

RESULTS

The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m² and 27.4 kg/m², respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group.

CONCLUSIONS

Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.