title: Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial.
abstract: BACKGROUND
  The ideal method for managing concomitant gallbladder stones and common bile duct (CBD) stones is debatable. The currently preferred method is two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy (LC). This prospective randomized trial compared the success and cost effectiveness of single- and two-stage management of patients with concomitant gallbladder and CBD stones.
  
  
  METHODS
  Consecutive patients with concomitant gallbladder and CBD stones were randomized to either single-stage laparoscopic CBD exploration and cholecystectomy (group 1) or endoscopic retrograde cholangiopancreatography (ERCP) for endoscopic extraction of CBD stones followed by LC (group 2). Success was defined as complete clearance of CBD and cholecystectomy by the intended method. Cost effectiveness was measured using the incremental cost-effectiveness ratio. Intention-to-treat analysis was performed to compare outcomes.
  
  
  RESULTS
  From February 2009 to October 2012, 168 patients were randomized: 84 to the single-stage procedure (group 1) and 84 to the two-stage procedure (group 2). Both groups were matched with regard to demographic and clinical parameters. The success rates of laparoscopic CBD exploration and ERCP for clearance of CBD were similar (91.7 vs. 88.1 %). The overall success rate also was comparable: 88.1 % in group 1 and 79.8 % in group 2 (p = 0.20). Direct choledochotomy was performed in 83 of the 84 patients. The mean operative time was significantly longer in group 1 (135.7 ± 36.6 vs. 72.4 ± 27.6 min; p ≤ 0.001), but the overall hospital stay was significantly shorter (4.6 ± 2.4 vs. 5.3 ± 6.2 days; p = 0.03). Group 2 had a significantly greater number of procedures per patient (p < 0.001) and a higher cost (p = 0.002). The two groups did not differ significantly in terms of postoperative wound infection rates or major complications.
  
  
  CONCLUSIONS
  Single- and two-stage management for uncomplicated concomitant gallbladder and CBD stones had similar success and complication rates, but the single-stage strategy was better in terms of shorter hospital stay, need for fewer procedures, and cost effectiveness.
authors.affiliation: Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India, drvkbansal@gmail.com.
authors.forename: Virinder Kumar
authors.initials: VK
authors.lastname: Bansal
authors.forename: Mahesh C
authors.initials: MC
authors.lastname: Misra
authors.forename: Karthik
authors.initials: K
authors.lastname: Rajan
authors.forename: Ragini
authors.initials: R
authors.lastname: Kilambi
authors.forename: Subodh
authors.initials: S
authors.lastname: Kumar
authors.forename: Asuri
authors.initials: A
authors.lastname: Krishna
authors.forename: Atin
authors.initials: A
authors.lastname: Kumar
authors.forename: Chandrakant S
authors.initials: CS
authors.lastname: Pandav
authors.forename: Rajeshwari
authors.initials: R
authors.lastname: Subramaniam
authors.forename: M K
authors.initials: MK
authors.lastname: Arora
authors.forename: Pramod Kumar
authors.initials: PK
authors.lastname: Garg
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D002769:Cholelithiasis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D007902:Length of Stay / Q000639:trends; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000379:methods; D016896:Treatment Outcome; D055815:Young Adult