Comparison of one stage laparoscopic cholecystectomy combined with intra-operative endoscopic sphincterotomy versus two-stage pre-operative endoscopic sphincterotomy followed by laparoscopic cholecystectomy for the management of pre-operatively diagnosed patients with common bile duct stones: a meta-analysis

Chester Tan, Omar Ocampo, Raymund Ong, Kim Shi Tan
Surgical Endoscopy 2018, 32 (2): 770-778

BACKGROUND: Laparoscopic cholecystectomy (LC) for symptomatic gallstone disease is one of the most common surgical procedures. Concomitant common bile duct (CBD) stones are detected with an incidence of 4-20% and the ideal management is still controversial. The frequent practice is to perform endoscopic sphincterotomy pre-operatively (POES) followed by LC, to allow subsequent laparoscopic or open exploration if POES fails. However, POES has shown different drawbacks such as need for two hospital admissions, need of two anesthesia inductions, higher rate of pancreatitis, and longer hospital stay. Hence, an intra-operative endoscopic sphincerotomy (IOES) has been proposed.

OBJECTIVE: To compare the 1 stage laparoscopic cholecystectomy (LC) combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis.

SEARCH STRATEGY: The search terms bile duct stones/calculi, ERCP, endoscopic sphincterotomy, laparoendoscopic rendezvous (LERV), and laparoscopic ductal clearance/choledochotomy/exploration were used. A comprehensive hand-based search of reference lists of published articles and review articles was performed to ensure inclusion of all possible studies and exclude duplicates.

SELECTION CRITERIA: RCTs comparing 1 stage LC combined with IOES versus 2-stage POES followed by LC for the management of pre-operatively known cholecystocholedocholithiasis in adults.

DATA COLLECTION & ANALYSIS: Three reviewers assessed trial quality and extracted the data. Data were entered in revman version 5.3. The trials were grouped according to the outcome measure assessed such as success rate of CBD stone clearance, incidence of pancreatitis, overall morbidity, and length of hospital stay.

MAIN RESULTS: A total of 629 patients in 5 RCTs met the inclusion criteria. The success rate of CBD clearance (IOES = 93%, POES = 92%) was the same in both groups (OR 1.34; 95% CI 0.45-0.97; p = 0.60). Findings showed that IOES was associated with less pancreatitis (0.6%) than POES (4.4%) (OR 0.19; 95% CI 0.06-0.67; p = 0.01; I 2  = 43%). The incidence of overall morbidity was lower in the IOES group (6%) than the POES group (11%) (OR 0.54; 95% CI 0.31-0.96; p = 0.03; I 2  = 20%). The mean days of hospital stay for IOES group (M = 3.52, SD = 1.434, N = 5) was significantly less than the POES group (M = 6.10, SD = 2.074, N = 5), t(8) = 2.29, p <= 0.051.

CONCLUSION: IOES is at par with two-stage POES in terms of CBD clearance, with less incidence of post-operative pancreatitis, overall morbidity, and less hospital stay.

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