One-Step Versus Two-Step Management of Choledocholithiasis: A Systematic Review and Metaanalysis

Abstract

Introduction: Laparoscopic common bile duct explorations (LCBDE) with laparoscopic cholecystectomy (1-step approach) or pre/post-operative endoscopic retrograde cholangiopancreatography (ERCP) (2-step approach) are two of the commonly employed methods for the treatment of choledocholithiasis. The optimal management is still controversial given varied results in the literature. We performed a metaanalysis to evaluate the outcomes of a single-stage versus double-stage approach in extracting common bile duct stones. Methods: PubMed/MEDLINE, Scopus, CINAHL, Cochrane databases, and recent abstracts from major conferences were searched (May 2014). Studies comparing the outcomes of 1-step with a 2-step approach for management of choledocholithiasis were included. Standard forms were used to extract data by two independent reviewers. Meta-analysis for outcomes of 1-step versus 2-step approach for management of choledocholithiasis was performed by calculating pooled estimates of stone clearance, procedure conversion, and morbidity by odds ratio (OR) with fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.2 was utilized for statistical analysis. Results: Seven randomized controlled trials and one observational study met the inclusion criteria (n=622). There was no statistically significant difference noted between 1-step versus 2-step approach for stone clearance (OR 0.95; 95% CI: 0.56-1.59; p=0.83), procedure conversion (OR 0.81; 95% CI: 0.40-1.65; p=0.56), or morbidity (OR 1.16; 95% CI: 0.76-1.77; p=0.50). Conclusion: Current evidence is insufficient to recommend either 1-step or a 2-step approach for the management of choledocholithiasis. Further large size randomized controlled trials are needed before final recommendations.