Updates in surgery · 2026
Transcystic and choledochotomy approaches of laparoscopic bile duct exploration show distinct outcomes against ERCP + laparoscopic cholecystectomy in a meta-analysis of randomised controlled trials.
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Ahmed Zeeshan, Thompson-Reil Colette, D'Souza Preethy, D'Souza Rovan, Ravishankar N, Sahay Samir, Davidson Brian R
Аннотация
BACKGROUND: Laparoscopic Common bile duct exploration (LCBDE), via transcystic or choledochotomy routes, offers a single-stage alternative to pre- or post-operative Endoscopic retrograde cholangiopancreatography with Laparoscopic cholecystectomy (ERCP + LC) to manage common bile duct stones. This meta-analysis compares the safety, efficacy, and outcomes of transcystic and choledochotomy approaches of LCBDE separately against ERCP +LC.
METHODS: PubMed, Embase, Cochrane Central, and Web of Science were searched to May 2024 for randomised controlled trials (RCTs). Eligible studies directly compared LCBDE with ERCP+LC. The primary outcome was ductal clearance. Secondary outcomes assessed procedure-specific complications (bile leak, stricture, pancreatitis, sepsis/cholangitis, blood loss and mortality), conversion to open surgery, cross-over, operative time, and hospital stay. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Eleven RCTs (n = 1472) met inclusion criteria.
RESULTS: Cumulative absolute event rates across all patients showed choledochotomy achieved the highest ductal clearance (93.5%) compared with transcystic (89.4%) and ERCP +LC (88.5%). Transcystic LCBDE showed the lowest overall morbidity but a higher ductal non-clearance rate (10.6%) and conversion to open surgery (3.5%). Pooled meta-analysis revealed choledochotomy was associated with significantly higher bile leak versus ERCP + LC (9.8% vs. 0.8%; RR 7.00, 95% CI 2.98-16.43, P < 0.00001) but lower blood loss requiring transfusion (0% vs. 2.5%; RR 0.29, 95% CI 0.08-0.98, P = 0.05). ERCP + LC carried higher risks of post-procedure pancreatitis (2.6% cumulative; pooled RR 0.40 favouring choledochotomy, P = 0.08).
CONCLUSIONS: The transcystic and choledochotomy approaches have distinct and complementary roles. Treatment selection should be guided by stone size, duct anatomy, and clinical context.
METHODS: PubMed, Embase, Cochrane Central, and Web of Science were searched to May 2024 for randomised controlled trials (RCTs). Eligible studies directly compared LCBDE with ERCP+LC. The primary outcome was ductal clearance. Secondary outcomes assessed procedure-specific complications (bile leak, stricture, pancreatitis, sepsis/cholangitis, blood loss and mortality), conversion to open surgery, cross-over, operative time, and hospital stay. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Eleven RCTs (n = 1472) met inclusion criteria.
RESULTS: Cumulative absolute event rates across all patients showed choledochotomy achieved the highest ductal clearance (93.5%) compared with transcystic (89.4%) and ERCP +LC (88.5%). Transcystic LCBDE showed the lowest overall morbidity but a higher ductal non-clearance rate (10.6%) and conversion to open surgery (3.5%). Pooled meta-analysis revealed choledochotomy was associated with significantly higher bile leak versus ERCP + LC (9.8% vs. 0.8%; RR 7.00, 95% CI 2.98-16.43, P < 0.00001) but lower blood loss requiring transfusion (0% vs. 2.5%; RR 0.29, 95% CI 0.08-0.98, P = 0.05). ERCP + LC carried higher risks of post-procedure pancreatitis (2.6% cumulative; pooled RR 0.40 favouring choledochotomy, P = 0.08).
CONCLUSIONS: The transcystic and choledochotomy approaches have distinct and complementary roles. Treatment selection should be guided by stone size, duct anatomy, and clinical context.