Early versus delayed laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis: a systematic review and meta-analysis of randomised controlled trials.

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the definitive treatment for choledocholithiasis after successful stone clearance via endoscopic retrograde cholangiopancreatography (ERCP). However, the optimal timing of surgery remains debated. This systematic review and meta-analysis compared early laparoscopic cholecystectomy (ELC ≤ 72 h) with delayed laparoscopic cholecystectomy (DLC > 72 h) after ERCP.

METHODS

A systematic search of MEDLINE, Embase, Scopus, and Cochrane Central was conducted from inception to September 1, 2025. Only randomised controlled trials (RCTs) comparing ELC with DLC after successful ERCP for choledocholithiasis were included. The primary outcomes were conversion to open surgery and operative time. Secondary outcomes included postoperative hospital stay, recurrent biliary events, intraoperative and postoperative complications, bile leak, and common bile duct (CBD) injury. Risk of bias was assessed using RoB 2.0, and the certainty of evidence was assessed using the GRADE tool.

RESULTS

Eight RCTs involving 576 patients (288 ELC, 288 DLC) were included. Moderate certainty evidence suggests that ELC probably reduces conversion to open surgery (RR 0.35; 95% CI: 0.17-0.68) and recurrent biliary events (RR 0.09; 95% CI: 0.03-0.28), and may reduce operative time (MD -17.63 min; 95% CI: -25.04 to -10.22), postoperative complications (RR 0.46; 95% CI: 0.26-0.82), and hospital stay (MD -0.52 days; 95% CI: -1.02 to -0.02). The evidence for rare complications such as CBD injury and bile leak remains very uncertain. Sensitivity analysis excluding trials with shorter ERCP-to-DLC intervals demonstrated consistent findings.

CONCLUSIONS

Moderate certainty evidence suggests that early laparoscopic cholecystectomy probably improves surgical and clinical outcomes following ERCP for choledocholithiasis. However, the evidence for rare complications remains very uncertain, and these findings should be interpreted in appropriately selected patients.