Transcystic or transductal stone extraction during single-stage treatment of choledochocystolithiasis: a systematic review.
BACKGROUND
Choledochocystolithiasis can be managed by endoscopic retrograde cholangiopancreaticography (ERCP) or laparoscopically by transcystic (TC) or transductal (TD) stone extraction.


OBJECTIVE
The aim of this study was to systematically review safety and effectiveness of combined endoscopic/laparoscopic management versus total laparoscopic management for choledochocystolithiasis with specific emphasis on TC versus TD stone extraction.


METHODS
MEDLINE/PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched systematically to identify trials on combined endoscopic/laparoscopic and total laparoscopic management for choledochocystolithiasis. Laparoscopic common bile duct (CBD) exploration was divided into TD and TC approach. Primary outcomes were successful stone clearance from CBD, postoperative/procedural morbidity, and mortality.


RESULTS
Eight randomized trials with 965 patients were included. Successful bile duct clearance varied between 52.6 and 97 % in the ERCP groups, 80.4 and 100 % in the TC groups, and 58.3 and 100 % in the TD groups. There were more bile leaks after TD stone extraction (11 %) than after ERCP (1 %) and TC stone extraction (1.7 %). Total morbidity varied between 9.1 and 38.3 % in the ERCP groups, 7 and 10.5 % in the TC groups, and 18.4 and 26.7 % in the TD groups. Methodological and statistical heterogeneity among the trials precluded a meaningful meta-analysis.


CONCLUSIONS
Stone clearance rates are comparable between the three modalities, but TD stone extraction is associated with a higher risk of bile leaks and should only be performed by highly experienced surgeons. TC stone extraction seems a more accessible technique with lower complication rates. If unsuccessful, per- or postoperative endoscopic stone extraction is a viable option.
Department of Surgery, St. Antonius Hospital, PO Box 2500, 3430 EM, Nieuwegein, The Netherlands, jansiertkay@gmail.com.
Jan Siert K
JS
Reinders
Dirk J
DJ
Gouma
Dirk T
DT
Ubbink
Bert
B
van Ramshorst
Djamila
D
Boerma
D001652:Bile Ducts / Q000601:surgery; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D042883:Choledocholithiasis / Q000601:surgery*; D042882:Gallstones / Q000601:surgery*; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D016717:Sphincterotomy, Endoscopic; D016896:Treatment Outcome