Keywords
Two-stage treatment
Common bile duct clearance
ERCP
Postoperative complications
Laparoscopic cholecystectomy
How to Cite
Abstract
Background: Cholecystocholedocholithiasis involves gallbladder and bile duct stones. Standard two-stage care involves ERCP followed by cholecystectomy, whereas single-stage intraoperative ERCP may streamline treatment. We performed a meta-analysis comparing stone clearance, complications, and hospital stay between single-stage and two-stage strategies.
Method: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Library up to April 2025 for clinical studies comparing one-stage laparo-endoscopic rendezvous with two-stage ERCP + LC. RCTs and observational studies reporting stone clearance, complications, conversion, bile leaks, hospital stay, repeat ERCP, or cannulation failure were included. Data extraction and ROB2/NOS assessments were done independently.
Result: Twenty-four studies met the inclusion criteria. The one-stage approach demonstrated significantly higher CBD clearance (96.5% vs. 91.8%; RR = 1.03) and a notably lower overall complication rate (11.55% vs. 19.56%; RR = 0.51). Postoperative pancreatitis (RR = 0.50), cholangitis (RR = 0.33), and bleeding (RR = 0.47) were also significantly reduced. Although conversion to open surgery and bile leak rates were lower in the one-stage group, these differences were not statistically significant. Importantly, single-stage management resulted in shorter hospital stays (mean difference = −3.23 days), fewer postoperative repeat ERCPs (RR = 0.21), and markedly reduced cannulation failure (RR = 0.26).
Conclusion: The one-stage approach for managing bile duct stones offers higher clearance rates, fewer complications, and shorter hospital stays compared to the two-stage approach. These results support adopting one-stage treatment as a more effective and efficient clinical strategy.
References
1. Ko CW, Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc. 2002: S165 [PMID: 12447261, https://doi.org/10.1067/mge.2002.129005]
2. Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol. 2006: 1075 [PMID: 17127189, https://doi.org/10.1016/j.bpg.2006.05.009]
3. U A, Cf W, Mw J. Laparoscopic Cholecystectomy. 2025.
4. Williams EJ, Green J, Beckingham I, Parks R, Martin D, Lombard M, British Society of G. Guidelines on the management of common bile duct stones (CBDS). Gut. 2008: 1004 [PMID: 18321943, https://doi.org/10.1136/gut.2007.121657]
5. Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg. 2012: 2011 [PMID: 22986769, https://doi.org/10.1007/s11605-012-2024-1]
6. Parra-Membrives P, Diaz-Gomez D, Vilegas-Portero R, Molina-Linde M, Gomez-Bujedo L, Lacalle-Remigio JR. Appropriate management of common bile duct stones: a RAND Corporation/UCLA Appropriateness Method statistical analysis. Surg Endosc. 2010: 1187 [PMID: 19915905, https://doi.org/10.1007/s00464-009-0748-0]
7. Wills VL, Gibson K, Karihaloot C, Jorgensen JO. Complications of biliary T-tubes after choledochotomy. ANZ J Surg. 2002: 177 [PMID: 12071447, https://doi.org/10.1046/j.1445-2197.2002.02308.x]
8. Byrne MF, McLoughlin MT, Mitchell RM, Gerke H, Kim K, Pappas TN, Branch MS, Jowell PS, Baillie J. For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures. Surg Endosc. 2009: 1933 [PMID: 19116743, https://doi.org/10.1007/s00464-008-0250-0]
9. Feretis C, Kalliakmanis B, Benakis P, Apostolidis N. Laparoscopic transcystic papillotomy under endoscopic control for bile duct stones. Endoscopy. 1994: 697 [PMID: 7859681, https://doi.org/10.1055/s-2007-1009068]
10. Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 2009: 338 [PMID: 19481184, https://doi.org/10.1016/j.ijsu.2009.05.005]
11. La Greca G, Barbagallo F, Di Blasi M, Di Stefano M, Castello G, Gagliardo S, Latteri S, Russello D. Rendezvous technique versus endoscopic retrograde cholangiopancreatography to treat bile duct stones reduces endoscopic time and pancreatic damage. J Laparoendosc Adv Surg Tech A. 2007: 167 [PMID: 17484642, https://doi.org/10.1089/lap.2006.0030]
12. Sterne JAC, Savovic J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernan MA, Hopewell S, Hrobjartsson A, Junqueira DR, Juni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019: l4898 [PMID: 31462531, https://doi.org/10.1136/bmj.l4898]
13. Lo CK, Mertz D, Loeb M. Newcastle-Ottawa Scale: comparing reviewers' to authors' assessments. BMC Med Res Methodol. 2014: 45 [PMID: 24690082, https://doi.org/10.1186/1471-2288-14-45]
14. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol. 2005: 13 [PMID: 15840177, https://doi.org/10.1186/1471-2288-5-13]
15. Sterne JA, Gavaghan D, Egger M. Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol. 2000: 1119 [PMID: 11106885, https://doi.org/10.1016/s0895-4356(00)00242-0]
16. Takada T. Tokyo Guidelines 2018: updated Tokyo Guidelines for the management of acute cholangitis/acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018: 1 [PMID: 29334699, https://doi.org/10.1002/jhbp.526]
17. Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, Barthet M, Domagk D, Dumonceau JM, Gigot JF, Hritz I, Karamanolis G, Laghi A, Mariani A, Paraskeva K, Pohl J, Ponchon T, Swahn F, Ter Steege RWF, Tringali A, Vezakis A, Williams EJ, van Hooft JE. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019: 472 [PMID: 30943551, https://doi.org/10.1055/a-0862-0346]
18. Ai C, Di LA, N T, G P, M P, A A, others. One-step versus two-step procedure for management of concurrent gallbladder and common bile duct stones: Outcomes and cost analysis. 2021.
19. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J, Faggioni A, Ribeiro VM, Jakimowicz J, Visa J, Hanna GB. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc. 1999: 952 [PMID: 10526025, https://doi.org/10.1007/s004649901145]
20. Prajapati RP, Vairagar SR, Banker AM, Khajanchi MU. Optimal timing of laparoscopic cholecystectomy post-endoscopic retrograde cholangiography and common bile duct clearance: A prospective observational study. J Minim Access Surg. 2022: 438 [PMID: 35708388, https://doi.org/10.4103/jmas.jmas_321_21]
21. Noel R, Arnelo U, Swahn F. Intraoperative versus postoperative rendezvous endoscopic retrograde cholangiopancreatography to treat common bile duct stones during cholecystectomy. Dig Endosc. 2019: 69 [PMID: 29947437, https://doi.org/10.1111/den.13222]
22. Morino M, Baracchi F, Miglietta C, Furlan N, Ragona R, Garbarini A. Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg. 2006: 889 [PMID: 17122614, https://doi.org/10.1097/01.sla.0000246913.74870.fc]
23. Bozkurt B, Soran A, Karabeyoglu M, Unal B, Coskun F, Cengiz O. Follow-up problems and changes in obliteration of the residual cystic cavity after treatment for hepatic hydatidosis. J Hepatobiliary Pancreat Surg. 2003: 441 [PMID: 14714165, https://doi.org/10.1007/s00534-003-0853-8]
24. ElGeidie AA, ElEbidy GK, Naeem YM. Preoperative versus intraoperative endoscopic sphincterotomy for management of common bile duct stones. Surg Endosc. 2011: 1230 [PMID: 20844893, https://doi.org/10.1007/s00464-010-1348-8]
25. Barreras Gonzalez JE, Torres Pena R, Ruiz Torres J, Martinez Alfonso MA, Brizuela Quintanilla R, Morera Perez M. Endoscopic versus laparoscopic treatment for choledocholithiasis: a prospective randomized controlled trial. Endosc Int Open. 2016: E1188 [PMID: 27857966, https://doi.org/10.1055/s-0042-116144]
26. Lella F, Bagnolo F, Rebuffat C, Scalambra M, Bonassi U, Colombo E. Use of the laparoscopic-endoscopic approach, the so-called "rendezvous" technique, in cholecystocholedocholithiasis: a valid method in cases with patient-related risk factors for post-ERCP pancreatitis. Surg Endosc. 2006: 419 [PMID: 16424987, https://doi.org/10.1007/s00464-005-0356-6]
27. Muhammedoglu B, Kale IT. Comparison of the safety and efficacy of single-stage endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy versus two-stage ERCP followed by laparoscopic cholecystectomy six-to-eight weeks later: A randomized controlled trial. Int J Surg. 2020: 37 [PMID: 32105889, https://doi.org/10.1016/j.ijsu.2020.02.021]
28. Rabago LR, Vicente C, Soler F, Delgado M, Moral I, Guerra I, Castro JL, Quintanilla E, Romeo J, Llorente R, Vazquez Echarri J, Martinez-Veiga JL, Gea F. Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis. Endoscopy. 2006: 779 [PMID: 17001567, https://doi.org/10.1055/s-2006-944617]
29. Sahoo MR, Kumar AT, Patnaik A. Randomised study on single stage laparo-endoscopic rendezvous (intra-operative ERCP) procedure versus two stage approach (Pre-operative ERCP followed by laparoscopic cholecystectomy) for the management of cholelithiasis with choledocholithiasis. J Minim Access Surg. 2014: 139 [PMID: 25013330, https://doi.org/10.4103/0972-9941.134877]
30. Tzovaras G, Baloyiannis I, Zachari E, Symeonidis D, Zacharoulis D, Kapsoritakis A, Paroutoglou G, Potamianos S. Laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: interim analysis of a controlled randomized trial. Ann Surg. 2012: 435 [PMID: 22261836, https://doi.org/10.1097/SLA.0b013e3182456ec0]
31. Liu Z, Zhang L, Liu Y, Gu Y, Sun T. Efficiency and Safety of One-Step Procedure Combined Laparoscopic Cholecystectomy and Eretrograde Cholangiopancreatography for Treatment of Cholecysto-Choledocholithiasis: A Randomized Controlled Trial. Am Surg. 2017: 1263 [PMID: 29183529,
32. Farid M, Baz A, Ramadan A, Elhorbity M, Amer A, Arafa A. Two institutes' experience in laparoendoscopic "rendezvous" technique for patients undergoing laparoscopic cholecystectomy for stones in the gallbladder and bile duct: a prospective randomized comparative clinical trial. Updates Surg. 2024: 2237 [PMID: 39320569, https://doi.org/10.1007/s13304-024-01973-6]
33. Garbarini A, Reggio D, Arolfo S, Bruno M, Passera R, Catalano G, Barletti C, Salizzoni M, Morino M, Petruzzelli L, Arezzo A. Cost analysis of laparoendoscopic rendezvous versus preoperative ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis. Surg Endosc. 2017: 3291 [PMID: 27924386, https://doi.org/10.1007/s00464-016-5361-4]
34. Jiang X, Yang G, Wang K, Bi W, Shang D, Zhang G. Clinical Efficacy Analysis of the Combination of the Laparoscope and Preoperative or Intraoperative Duodenoscope in the Treatment of Cholecystolithiasis with Choledocholithiasis: A Retrospective Study. J Laparoendosc Adv Surg Tech A. 2019: 1539 [PMID: 31647359, https://doi.org/10.1089/lap.2019.0541]
35. Meyer C, Le JV, Rohr S, Thiry LC, Bourtoul C, Duclos B, Reimund JM, Baumann R. Management of common bile duct stones by laparoscopic cholecystectomy and endoscopic sphincterotomy: pre-, per- or postoperative sphincterotomy? Dig Surg. 1999: 26 [PMID: 9949264, https://doi.org/10.1159/000018690]
36. Muhammedoğlu B. Single-stage treatment with ERCP and laparoscopic cholecystectomy versus two-stage treatment with ERCP followed by laparoscopic cholecystectomy within six to eight weeks: a retrospective study. Turkish Journal of Surgery. 2019: 178 https://doi.org/10.5578/turkjsurg.4204]
37. Passi M, Inamdar S, Hersch D, Dowling O, Sejpal DV, Trindade AJ. Inpatient Choledocholithiasis Requiring ERCP and Cholecystectomy: Outcomes of a Combined Single Inpatient Procedure Versus Separate-Session Procedures. J Gastrointest Surg. 2018: 451 [PMID: 28971298, https://doi.org/10.1007/s11605-017-3588-6]
38. Qian Y, Xie J, Jiang P, Yin Y, Sun Q. Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy for the management of cholecysto-choledocholithiasis: a retrospectively cohort study. Surg Endosc. 2020: 2483 [PMID: 31428853, https://doi.org/10.1007/s00464-019-07051-y]
39. Gerosa M, Guttadauro A, Stillittano DF, Sassun R, Sileo A, Vignati B, Di Fratta E, Maggioni D, Mari G. Single stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography for cholecysto-choledocholithiasis. Lesson learnt from the COVID-19 pandemic. Front Surg. 2024: 1398854 [PMID: 38957742, https://doi.org/10.3389/fsurg.2024.1398854]
40. Mohamed MA, Gaber R A, Saada A, Fouad HF, Ismail MMA, Yousef A M. Single-session endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) vs. Two-stage Endoscopic Stone Extraction during ERCP followed by LC: a multicenter experience. The Egyptian Journal of Surgery. 2023: 603 https://doi.org/10.4103/ejs.ejs_116_23]
41. Percario R, Panaccio P, Caldarella MP, Trappoliere M, Marino M, Farrukh M, Di Giacomo C, Di Martino G, De Nobili G, di Renzo RM, Grottola T, Di Sebastiano P, di Mola FF. Laparoendoscopic Rendezvous: An Effective and Safe Approach in the Management of Cholecysto-Choledocholithiasis in Selected Patients. J Clin Med. 2025: [PMID: 40004839, https://doi.org/10.3390/jcm14041310]
42. Raab S, Jagoditsch A, Kurz F, Pimingstorfer P, Schimetta W, Schofl R, Schrenk P, Schwinghammer C, Ziachehabi A, Shamiyeh A. Comparison of intraoperative versus preoperative ERCP with laparoscopic cholecystectomy for cholecystocholedocholithiasis: a 3-year study at Kepler University Hospital. Surg Endosc. 2025: 1036 [PMID: 39681682, https://doi.org/10.1007/s00464-024-11438-x]
43. Y HZaJFaQ. Comparison of the efficacy of one-step and step-by-step surgical treatment for gallbladder stones complicated with common bile duct stones.
44. Lv S, Wang B, Hu P, Shi B, Zhang W, Wang A. Efficacy analysis of hybrid operating room-based laparoscopic cholecystectomy combined with intraoperative endoscopic retrograde cholangiopancreatography in the treatment of cholelithiasis combined with choledocholithiasis - A case-control study. J Minim Access Surg. 2023: 402 [PMID: 37282422, https://doi.org/10.4103/jmas.jmas_180_22]
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Copyright (c) 2025 Mohamed Gamal, Mohamed Wagdy, Mahmoud Abd El-Nasser, Abdalla Ahmed Mohamed, Abdelrhman Waleed Kotb, Abdulrahman Ziada, Abdelrahman Abdalla Mohamed