Two-stage vs single-stage management for concomitant gallstones and common bile duct stones.
OBJECTIVE
To evaluate the safety and effectiveness of two-stage vs single-stage management for concomitant gallstones and common bile duct stones.


METHODS
Four databases, including PubMed, Embase, the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011, were searched to identify all randomized controlled trials (RCTs). Data were extracted from the studies by two independent reviewers. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, number of procedures per patient, length of hospital stay, total operative time, hospitalization charges, patient acceptance and quality of life scores.


RESULTS
Seven eligible RCTs [five trials (n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (EST) + laparoscopic cholecystectomy (LC) with LC + laparoscopic common bile duct exploration (LCBDE); two trials (n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE], composed of 787 patients in total, were included in the final analysis. The meta-analysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios (RR) = -0.10, 95% confidence intervals (CI): -0.24 to 0.04, P = 0.17], postoperative morbidity (RR = 0.79, 95% CI: 0.58 to 1.10, P = 0.16), mortality (RR = 2.19, 95% CI: 0.33 to 14.67, P = 0.42), conversion to other procedures (RR = 1.21, 95% CI: 0.54 to 2.70, P = 0.39), length of hospital stay (MD = 0.99, 95% CI: -1.59 to 3.57, P = 0.45), total operative time (MD = 12.14, 95% CI: -1.83 to 26.10, P = 0.09). Two-stage (LC + ERCP/EST) management clearly required more procedures per patient than single-stage (LC + LCBDE) management.


CONCLUSIONS
Single-stage management is equivalent to two-stage management but requires fewer procedures. However, patient's condition, operator's expertise and local resources should be taken into account in making treatment decisions.
Department of Bile Duct Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China.
Jiong
J
Lu
Yao
Y
Cheng
Xian-Ze
XZ
Xiong
Yi-Xin
YX
Lin
Si-Jia
SJ
Wu
Nan-Sheng
NS
Cheng
D016009:Chi-Square Distribution; D002681:China; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000401:mortality; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000401:mortality; D042883:Choledocholithiasis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D019317:Evidence-Based Medicine; D042882:Gallstones / Q000150:complications / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012307:Risk Factors; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome