Single-Stage vs. Two-Stage Management for Concomitant Gallstones and Common Bile Duct stones: A Prospective Randomized Trial with Long-Term Follow-up

The preferred approach to the management of common bile duct (CBD) stones is uncertain, with single-stage laparoscopic cholecystectomy and CBD exploration vs. two-stage preoperative endoscopic CBD clearance followed by laparoscopic cholecystectomy being debated. To address this, a prospective randomized study which compared these two management strategies was undertaken. Between Jan 2002 and Dec 2005, patients with gallstones and common bile duct stones diagnosed by preoperative ultrasonography and magnetic resonance cholangiopancreatography were randomized to single-stage vs. two-stage treatment. In a single-stage group, laparoscopic cholecystectomy and CBD exploration were undertaken at the same operation, whereas in a two-stage group, endoscopic stone clearance was followed by laparoscopic cholecystectomy 2-5 days later. Early treatment success and complications and longer-term follow-up for the two groups were compared. Two hundred twenty-one patients were enrolled in the trial, 110 in the single-stage group and 111 in the two-stage group. There was no significant difference in the success rate of CBD clearance (93.6 vs. 94.6 %, p = 0.76) or the complication rates (3.6 vs. 5.1 %, p = 0.527) between the groups. However, at longer-term follow-up, recurrent CBD stones were seen more often in the two-stage group (9.5 vs. 2.1 %, p = 0.037). The single-stage and two-stage approaches were equally effective in achieving initial clearance of CBD stones. However, recurrent CBD stones occurred more commonly in patients who had undergone two-stage treatment with initial endoscopic stone clearance, followed by laparoscopic cholecystectomy.