Meta-analysis of the efficacy of a single stage laparoscopic management versus two-stage endoscopic management of symptomatic gallstones with common bile duct stones.

Background. The optimal treatment of gallstones with associated common bile duct stones in the laparoscopic era is controversial. Various reviews and decision based algorithms have been published, but the superior treatment modality is unclear. Therefore, a metaanalysis was conducted to compare the two most commonly used treatment strategies.

Methods. A systematic review was conducted to compare single stage laparoscopic cholecystectomy with common bile duct exploration versus a combined endoscopic and laparoscopic treatment. Eligible studies were identified using a search of Medline, Embase, Cochrane and Science Citation Index Expanded databases. Appropriately selected articles were independently reviewed and data was extracted and cross referenced. A meta-analysis was conducted of the pooled trial data to determine difference in outcomes.

Results. A total of seven randomized trials were identified with 746 patients with 366 in the laparoscopic only treatment group and 380 in the combined endoscopic and laparoscopic treatment arms. There was no significant difference in successful bile duct clearance between the two groups (OR 1.23; 95% CI 0.55 to 2.75, P = 0.61). There was no statistical difference in morbidity (RR 1.23; 95% CI 0.92 to 1.66; P = 0.17), mortality (RD -0.00; 95% CI -0.02 to 0.01, P = 0.59) or length of hospital stay (MD -0.31; 95% CI -1.68 to 1.06, P = 0.66). However, there was a statistically significant difference in the duration of procedure in favour of the single stage laparoscopic treatment (MD -6.83; 95% CI -9.59 to -4.07, P < 0.00001).

Conclusion. Both the laparoscopic alone or the combined endoscopic and laparoscopic treatment approaches show comparative efficacy in management of symptomatic gallstones with associated choledocholithiasis.