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: ERCP; biliary; gastrointestinal; general surgery; minimally invasive surgery.