One- and Two-Stage Approaches to Common Duct Stones

Abstract

The prevalence of cholelithiasis is estimated to be upwards of 30% within the United States population. Of these patients, 10-20% will progress to develop choledocholithiasis. Prior to 2000, choledocholithiasis was managed via open cholecystectomy and common bile duct exploration. However, as minimally invasive surgical techniques and endoscopy have advanced, the current management of choledocholithiasis has progressed to a two-staged, laproendoscopic approach consisting of endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy. Review of the literature from 2005 to 2025 reveals that the preferred approach to choledocholithiasis continues to evolve. Management of choledocholithiasis via a single-stage such as performing intraoperative ERCP at the time of laparoscopic cholecystectomy is associated with a statistically significant decrease in overall 30-day morbidity as well as shorter hospital length of stay compared with a twostaged laproendoscopic approach. Alternatively, performing intraoperative rendezvous endoscopy significantly improves patient morbidity profiles due the absence of post-endoscopic pancreatitis compared with ERCP. A third management option includes laparoscopic common bile duct exploration via a transcystic or transductal approach. These approaches are associated with superior stone clearance rates compared with ERCP as well as decreased cost and hospital length of stay. Barriers to implementation of these techniques include surgeon training, equipment availability, and appropriate staffing. Future studies should investigate the role of robotic surgery in the management of choledocholithiasis as well as compare patient centered outcomes between the three, single-staged approaches.

Keywords

biliary ERCP gastrointestinal general surgery minimally invasive surgery

Introduction

It is estimated that up to 30% of individuals have cholelithiasis.^1,2 Fortunately, only 13-22% of patients will experience symptoms related to their gallstones, with these symptoms largely dictated by the location of obstruction.² A gallstone that becomes lodged in the common bile duct (CBD) is referred to as choledocholithiasis. An estimated 10-20% of individuals with cholelithiasis will progress to choledocholithiasis.² While the management of cholelithiasis is not emergent, choledocholithiasis must be addressed promptly due to complications carrying a mortality rate of up to 10%.²

The management of choledocholithiasis has evolved alongside advancements in laparoscopy and endoscopy. Prior to 2000, choledocholithiasis was managed as a one-staged surgical operation performed via open common bile duct exploration (CBDE) because endoscopic options had lower stone clearance and higher mortality rates.³ With advancements in technique, a two-staged approach via endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy quickly became the mainstay of treatment for CBD stones.² This approach is currently supported as a recommendation with level one evidence in gallstone disease management guidelines.² However, in recent years, there has been a large volume of literature published investigating the feasibility of returning to a one-staged, minimally invasive CBDE approach to CBD stones, if the required surgical expertise is present to improve patient outcomes and decrease hospital expenditures.^1,4

The primary aim of this paper is to provide a comprehensive, 20-year review of published literature regarding the management of choledocholithiasis in the general patient population as well as special populations including the elderly patient, the pregnant patient, and the patient with altered anatomy.

Materials and Methods

Search Strategy

The PubMed Central database was utilized to identify pertinent articles. The following keywords were used: common bile duct stones, choledocholithiasis, surgical management, pregnancy, elderly, altered anatomy. The database search was restricted to free, full text options available in English. Ethical approval was not necessary for this study.

Eligibility Criteria

Studies were selected from 2005 and 2025. The following article types were included: books and documents, clinical trials, comparative studies, equivalence trials, evaluation trials, randomized controlled trials, systematic reviews, and analysis. Articles were excluded if they were not available in English, greater than 20 years old, or if only an abstract was available for review.

Article Selection

A total of 674 articles were initially identified. After selecting for the article types mentioned, 199 manuscripts were identified. Articles were further filtered for the appropriate time frame resulting in 89 articles being selected for review. Articles that were included in this review included articles that evaluated the management of choledocholithiasis via one stage or two stage approaches, including common duct exploration, and ERCP, or a combination of other surgical and endoscopic interventions.

Results

Open Common Bile Duct Exploration

Historically, choledocholithiasis was managed as a single-staged operation consisting of open cholecystectomy followed by CBDE. This procedure involved a choledochotomy, clearance of the CBD down to the level of the sphincter of Odi, followed by duct closure either primarily, over a T-tube, or over a transcystic drain.⁵ This approach has fallen out of favor due to the availability of minimally invasive approaches to both cholecystectomy and ductal clearance with improved patient outcomes, such as a statistically significant decrease in hospital length of stay (4.2 vs 12.6 days) and intraoperative blood loss (20 ± 2 vs 285 ± 27 mL; P < 0.01).⁵

Endoscopic Retrograde Cholangiopancreatography

A two-stage approach for management of choledocholithiasis is the current standard of practice. In the first stage, patients undergo ERCP with CBD cannulation. Due to the close approximation of the pancreatic duct and the CBD, there is a known risk of inadvertent pancreatic duct cannulation possibly resulting in post-ERCP pancreatitis (PEP). Because of this risk, patients are typically observed for one to two days prior to proceeding with post-ERCP laparoscopic cholecystectomy extending patient length of stay. Laparoscopic cholecystectomy is performed during the same hospitalization; there is little role for delay to the outpatient setting. Meta-analyses have shown that performing an ERCP followed by laparoscopic cholecystectomy in the same hospitalization decreases the risk of acute cholecystitis, biliary cholangitis, and improves mortality rates in comparison to delayed laparoscopic cholecystectomy.^6,7

Intraoperative endoscopic options such as intraoperative ERCP are also available. A meta-analysis found that patients undergoing laparoscopic cholecystectomy with intraoperative ERCP have a lower overall 30-day morbidity rate (RR: 0.57, 95% CI = 0.41-0.79, P = 0.0008) and decreased incidence of PEP in comparison with patients who received endoscopic intervention preoperatively (RR: 0.29, 95% CI = 0.13-0.67, P = 0.004).⁸ There was no statistical difference in stone clearance rates when comparing pre-operative to intraoperative ERCP (RR: 1.01, 95% CI = 0.98-1.04, P = 0.61, I² = 10%).⁸ A second meta-analysis found that intraoperative ERCP was associated with a shorter hospital length of stay (MD −2.75, 95% CI [−3.51 to −2.00], P < .05) and was associated with a lower overall morbidity rate (RR 0.54, 95% CI [0.39-0.76], P < .05) compared to preoperative ERCP.⁹

Technical challenges to performing intraoperative ERCP with laparoscopic cholecystectomy include positioning, bowel distention, and equipment availability. ERCP is typically performed in the left lateral decubitus or prone position whereas laparoscopic cholecystectomy is performed in the supine position. Performing both procedures concurrently without patient repositioning increases the difficulty of the procedure.⁷ During ERCP, intraluminal bowel dilation occurs secondary to CO2 insufflation and can impede visibility intra-abdominally for the laparoscopic portion. Additionally, performing intraoperative ERCP requires the use of a portable C-arm, or it requires an operating room designed specifically for laproendoscopic procedures.

Transcystic Common Bile Duct Exploration

Minimally invasive CBDE can be performed via two approaches: transcystic or transductal. In a transcystic approach, an incision is created within the cystic duct and the duct is accessed with a 3 mm choledochoscope. Stones are retrieved under direct visualization using a Dormia basket or flushing with saline.^11,12 Once cleared, the scope is removed, and the cystic duct is clipped closed with clips.¹²

Several parameters must be met for a transcystic approach to be successful. First, the cystic duct must be large enough to allow passage of scope; ducts less than 3 mm with highly friable tissue will not be successfully navigated. Generally, the CBD should be less than 8-10 mm with stones less than 1 centimeter (cm) in size.¹² Larger or multiple stones can be difficult to retrieve and can be displaced into the proximal CBD unable to be reached.¹³

Compared with a transductal approach, a transcystic approach has a slightly lower CBD clearance rate (93.7% vs 100%); however, this risk is noted to be outweighed by the benefit of a significantly improved morbidity profile primarily attributed to lower rates of bile leak (OR 0.46, 95% CI 0.23 to 0.93).¹³ There is no evidence showing that a transcystic approach has higher rates of reintervention.¹¹

Transductal Common Bile Duct Exploration

When performing a transductal CBDE, a vertical choledochotomy is created followed by removal of stones in a similar fashion to a transcystic approach.¹² A critical difference is noted during closure. The CBD can be closed primarily with an absorbable suture; however, bile leak rates are improved if there is biliary decompression via a T-tube or an antegrade CBD stent. Closure over a T-tube is inferior because of risk attributed to bile peritonitis without significant improvement in patient outcomes.¹¹ Antegrade stents have been found to decrease post-operative length of stay and complication rates (0% vs 11%) compared with T-tubes.¹¹

A transductal approach is preferred for large stones, >1 cm. Stone clearance rates approach nearly 100%; however, the rate of bile leak is significantly higher compared with a transcystic approach or ERCP (8.7% vs 3.2% vs 3.8%).¹⁴ These results are corroborated by a large meta-analysis with similar findings.¹³ Studies have shown that a CBD less than 1 cm has a significantly increased rate of bile leak (upwards of 30%) compared to a CBD greater than 1 cm (7%).^15,16 Regardless of whether transcystic vs transductal CBDE is performed, it is crucial to perform a completion cholangiogram is performed following stone removal to ensure duct clearance.

In recent years, there is a growing body of literature supporting a single-stage approach to choledocholithiasis as the superior approach. A meta-analysis comparing one stage CBDE to two stage ERCP followed by laparoscopic cholecystectomy, revealed that a single-staged approach was non-inferior to ERCP.¹⁷ Minimally invasive CBDE has a significantly shorter hospital length of stay (2-5 vs 4-9 days, P > 0.001) and improved hospital costs compared to ERCP followed by laparoscopic cholecystectomy.^18,19 A retrospective comparative analysis found that patients undergoing laparoscopic CBDE had a significant reduction in the rate of choledocholithiasis recurrence long term.²⁰ Another single center, prospective randomized trial showed that transductal and transcystic laparoscopic CBDE both had higher CBD clearance rates compared with ERCP.¹⁴

Rendezvous Endoscopy

Rendezvous endoscopy is a form of endoscopy that can be utilized as an alternative to ERCP during laparoscopic cholecystectomy. After laparoscopic identification and isolation of the cystic duct, a small ductotomy is created and a wire is threaded through the CBD and into the duodenum via the major papilla.⁹ A scope is then inserted periorally and advanced until the wire is identified. Using the wire as a guide, the CBD is cannulated and cleared of stones and debris.

This approach is advantageous because it allows for easy identification of the papilla and direct cannulation of the CBD without pancreatic duct involvement. There is a significant reduction in overall patient morbidity (OR 0.41, P < 0.0001) and of PEP (OR 0.26, P = 0.0003) because of guided CBD cannulation compared with ERCP.²¹ This approach also allows for a single stage approach to CBD stones associated with a decreased length of hospital stay and cost.^21,22 Meta-analysis found that a laparoendoscopic rendezvous approach appears to decrease hospital stay by 3 days compared to ERCP.²³ A second meta-analysis found the rendezvous approach to be superior to laparoscopic CBDE citing similar duct clearance rates and an improved morbidity due to the absence of risk of bile leak.²⁴

Approach to the Elderly Patient

Elderly patients, specifically those greater than 75 years of age, are at increased risk of choledocholithiasis, representing about 20% of cases, compared to younger patients.²⁵ Treatment options for the elderly required additional consideration due to their increased comorbidity profile, ASA category, and altered physiologic reserve.² An additional treatment option for the elderly includes ERCP with sphincterotomy and stent placement for definitive stone management.²⁶ This may be the sole treatment option for a patient of poor condition.²⁶ However, studies have shown laparoscopic cholecystectomy is protective against recurrent, late cholecystitis.^25,27 Recent data has also shown that laparoscopic CBDE in elderly patients can be safely performed despite increased comorbidity and ASA category without significantly increasing patient length of stay, readmission rate, or post-operative complication rate.^12,28 Therefore, each patient should be approached with individual assessment.

Approaches to Pregnancy

Approximately 1 in 1000 pregnant patients with cholelithiasis will experience choledocholithiasis. With the current two-staged approach, the largest concern in treating this population is fetal radiation exposure during ERCP. It is well established that the first trimester of pregnancy poses the greatest risk to the fetus and cumulative radiation exposure should not exceed 100 milliGray.²⁹ Fortunately, ERCP can be safely performed in pregnant patients without the use of radiation.^29-32 As an alternative to fluoroscopy, CBD cannulation can be confirmed via bile aspiration or visualization of leakage around the cannulation wire.³² There is currently no published literature reporting adverse fetal outcomes with this approach; however, some studies recommend performing ERCP only after entering the second trimester.²⁹

It is well known the laparoscopic cholecystectomy is safe to perform in pregnant patients with no morbidity or mortality to the fetus in all trimesters of pregnancy.³³ If laparoscopic cholecystectomy cannot be performed, one study found that ERCP with plastic stent placement allowed patients to be safely managed during pregnancy with an additional ERCP and stent removal after delivery.³¹

Approaches to Altered Anatomy

Altered anatomy poses an endoscopic challenge and requires a high-volume center for treatment. Examples of altered anatomy include Billroth II reconstruction, hepaticojejunostomy or Roux-en-Y reconstruction. If performing a two-staged operation, there are a breadth of endoscopes and approaches available to clear CBD stones in this such as duodenoscopes, forward viewing endoscopes, and device-assisted enteroscopy like laparoscopic-assisted transgastric ERCP.^11,34 Minimally invasive CBDE via a single-staged approach is a second treatment option within this patient population but requires appropriate patient counseling and surgical expertise. It is associated with increased operative times and rate of conversion to an open procedure (6.7%-14.9%) attributed to the patient’s likely extensive prior abdominal surgical history.¹¹

Discussion

The evolution of choledocholithiasis management has progressed from a one-staged, open surgical approach to a two-staged laproendoscopic approach. However, in recent years, minimally invasive CBDE has been proven to be safe and successful. After thorough review of the literature, management of choledocholithiasis will likely return to a one-stage approach in the future either via laparoscopic transcystic CBDE or rendezvous endoscopy. While both approaches have a paucity of data to support the transition from a two-staged approach, there are functional and clinical implementation barriers to consider.

From a CBDE perspective, the necessary equipment needs to be readily available for operating surgeons. One institution found they were unable to routinely implement transcystic exploration because no choledochoscopes were available for use.⁷ Secondly, laparoscopic CBDE is technically challenging and expert surgical training is required. One study cites limited use of this technique by surgeons secondary to feeling their training in this area was inadequate.³⁵ This raises a concern that there is a gap in robust laparoscopic training with regards to bile duct intervention and exploration.

Implementing a one-staged, laproendoscopic approach also has system-wide challenges, specifically regarding scheduling and staffing availability. These interventions require the availability of highly trained endoscopists and surgeons. There are very few minimally invasive surgeons that are also highly trained to perform their own endoscopy. This raises an interesting question, should there be required, formal advanced endoscopic training for minimally invasive surgeons? Aside from staffing concerns, performing intraoperative scopes requires the necessary tools and technology be available within the operating room as well as staff with experience operating the technology.¹⁰ This is not easily implemented at smaller institutions who are resource limited or at larger institutions where provider schedule coordination is challenging.

There have been studies that note a one-stage operation decreases hospital costs; however, there is no data showing that the cost savings would outweigh the expenditure of increased staffing, training, equipment availability, and prolonged operating room times.^{18,19,21,22,36} Also, ultimately, there is no data that patient quality of life would be improved via this approach. Further studies should investigate patient centered outcomes with regards to a one- vs a two-staged approach and perform detailed costs analysis on its implementation. Future studies are also required to compare head-to-head outcomes with regards to ERCP vs rendezvous endoscopy. Of note, within the literature there is no examination beyond case reports or case series regarding the role of robotic surgery in CBDE. As the advent of robotic surgery increases, further studies should investigate its role in the one-staged approach to choledocholithiasis.

Conclusion

In conclusion, the current management of choledocholithiasis is via a two-staged approach utilizing ERCP followed by laparoscopic cholecystectomy. There is a growing body of literature that has shown advantages of a one-staged approach either via intraoperative rendezvous endoscopy or laparoscopic CBDE, citing improvements in hospital length of stay, lower postoperative complication rates, specifically with regards to PEP, and lower hospital cost. The implementation of a one stage approach is clinically and functionally challenging. This approach exposes a gap within surgical training regarding expertise of laparoscopic CBDE. Future studies should investigate patient centered outcomes after implementation of a one-stage approach, the role of robotic surgery in CBDE, as well as detailed cost-analysis comparing one- vs two-staged approaches.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Shannon M. Smith

Jesse K. Kelley

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