Optimizing common bile duct stone management: Single-stage laparoscopic exploration versus two-stage ERCP and cholecystectomy

Single-stage versus two-stage CBD stone management

Abstract

Background/Aim: Concomitant gallbladder and common bile duct (CBD) stones can be managed with a single-stage operative pathway, including laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC), or with a two-stage strategy using preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC during the same admission. In this randomized controlled trial, we compared these strategies in terms of perioperative safety, overall effectiveness, and patient recovery experience.

Methods: A total of 200 patients with gallstones and CBD stones were enrolled between January 2016 and December 2024 and randomized using sealed opaque envelopes to Group I, single-stage LCBDE + LC (n = 100), or Group II, two-stage ERCP + LC (n = 100). The primary outcome was successful CBD stone clearance and gallbladder removal using the assigned approach without conversion. Secondary outcomes included postoperative pain, complications, hospital stay, retained CBD stones, and patient satisfaction. Data were analyzed using SPSS version 26, and statistical significance was defined as a two-tailed P-value <0.050.

Results: Baseline demographic characteristics were similar between groups. Mean CBD diameter and stone size were larger in Group I than in Group II [13.18 (2.01) mm vs. 10.94 (2.46) mm, P <0.001; and 6.29 (1.47) mm vs. 5.65 (1.69) mm, P = 0.005, respectively]. Mean operative time was comparable [138.3 (20.4) min vs. 140.85 (43.98) min, P = 0.600]. Intraoperative complication and conversion rates were low and comparable. Postoperative direct bilirubin levels were slightly higher in Group I [1.01 (0.08) mg/dL vs. 0.83 (0.06) mg/dL, P = 0.030]. Early pain scores at 24 h favored Group I [5.34 (1.02) vs. 6.30 (1.02), P <0.001], whereas day 3 pain scores were similar. Retained CBD stones were rare [3% vs. 0%, P = 0.246]. Hospital stay, overall complications, and patient satisfaction were comparable between groups.

Conclusion: Single-stage LCBDE + LC was as safe and effective as two-stage ERCP + LC and was associated with better early pain control and potential resource advantages through single-session treatment. Both strategies remain viable options, and the preferred approach should be guided by patient anatomy, local expertise, available resources, and institutional logistics.