Laparoscopic common bile duct exploration versus preoperative endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy for choledocholithiasis: a narrative review

Introduction

Background

Choledocholithiasis, or the presence of common bile duct (CBD) stones, occurs in approximately 10–15% of patients with symptomatic cholelithiasis and remains a frequent indication for biliary intervention (1). Management generally employs two main approaches: a single-stage technique involving laparoscopic common bile duct exploration (LCBDE) and a two-stage technique consisting of preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) (2). Large national database studies have demonstrated a significant decrease in CBD exploration rates from 39.8% of admissions in 1998 to 8.5% in 2013 across both open and laparoscopic approaches (laparoscopic 9.2% vs. 3.0%), while ERCP + LC increased from 52.8% to 85.7% during the same period (3). Although these data reflect earlier practice patterns, they illustrate a growing reliance on endoscopic management and may be influenced by differences in institutional expertise, training exposure, and resource availability rather than definitive evidence of clinical superiority.

Rationale and knowledge gap

In recent years, multiple randomized controlled trials (RCTs) and meta-analyses have compared these two strategies to evaluate differences in efficacy, safety, and cost-effectiveness as advances in both endoscopic and laparoscopic techniques have expanded therapeutic options (4-8). Many of these studies demonstrate comparable or superior ductal clearance, similar overall morbidity, and shorter hospital length of stay in selected populations; however, national data continue to show a decline in the utilization of LCBDE, highlighting a potential disconnect between published evidence and real-world practice patterns. Prior analyses have frequently focused on RCTs and short-term clinical endpoints, often excluding large contemporary observational cohorts, cost analyses, institutional practice pattern data, and patient-reported outcomes. As minimally invasive techniques, choledochoscopy technology, and institutional training models continue to evolve, an updated integrative review incorporating recent comparative data is warranted.

Objective

This narrative review aims to summarize and compare outcomes between LCBDE and preoperative ERCP for the management of preoperatively identified or suspected CBD stones. This review focuses specifically on patients with preoperatively suspected or confirmed CBD stones and does not address retained stones identified after LC. The review focuses on key clinical metrics including ductal clearance, complications, hospital length of stay, technical and institutional considerations, and patient-centered outcomes to provide a clinically relevant, practice-oriented comparison of these strategies. We present this article in accordance with the Narrative Review reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-66/rc).

Methods

Search strategy and selection criteria

A structured literature search was conducted to identify studies comparing LCBDE and preoperative ERCP followed by LC. The search was designed to ensure transparent and reproducible methodology, consistent with the standards of a narrative review.

Searches were performed in PubMed/Medline and Google Scholar through October 1^st 2025, using combinations of Medical Subject Headings (MeSH) and free-text terms including “common bile duct stones”, “choledocholithiasis”, “laparoscopic common bile duct exploration”, “ERCP”, “endoscopic retrograde cholangiopancreatography”, “laparoscopic cholecystectomy”, and “two-stage management”. No date restrictions were applied to allow inclusion of both historical and contemporary evidence. Only English-language human studies were included. Reference lists of relevant articles were also manually reviewed to identify additional citations. A study selection flow diagram can be viewed in Figure 1.

Figure 1 Study selection flow diagram.

Inclusion and exclusion criteria

Studies were included if they directly compared LCBDE and ERCP + LC in adult patients with CBD stones and reported at least one outcome of interest: ductal clearance, complications, length of stay, cost or patient-centered outcomes. Meta-analyses, RCTs, prospective or retrospective comparative cohorts, and large observational series were eligible. Two-stage management was defined as preoperative ERCP followed by LC. Studies in which LC was performed prior to ERCP (LC followed by ERCP) were excluded, as these represent intraoperatively diagnosed or retained CBD stones and a different treatment pathway. Pediatric studies, single-case reports, and purely diagnostic studies were excluded.

Selection process

The primary author (K.B.) independently screened titles and abstracts for relevance. Full texts were reviewed when necessary, and literature search was verified by principal investigator (J.L.L.) to ensure consensus and completeness. Please refer to Table 1 for further search strategy details. A summary of the characteristics of included studies is provided in Table 2.

Key content and main findings

The final included studies, after screening, consisted of studies published between 2003 and 2025, including RCTs, meta-analyses, and observational series directly comparing LCBDE with preoperative ERCP followed by LC. Collectively, these studies provide comprehensive insight into the comparative efficacy, safety, and practicality of single- versus two-stage management of choledocholithiasis. Key comparative outcome measures are summarized in Tables 3-5.

Ductal clearance and efficacy

Across the available literature, ductal clearance rates were comparable or superior for LCBDE compared with ERCP + LC. Multiple randomized and observational studies reported significantly higher clearance rates with LCBDE, ranging from 88–100%, compared to 72–89% for the two-stage group (5,6,12,28). In contrast, a few analyses favored the two-stage procedure, with clearance rates of 78% vs. 63% for LCBDE (11). Most studies, however, demonstrated equivalence, with clearance between 92% and 97% across both approaches (4,7,26,27).

Single-stage exploration showed particular advantages for multiple or large stones, where ERCP success decreased (5,12). In addition to stone burden, anatomical factors such as cystic duct diameter, ductal alignment, and papillary anatomy may influence procedural success, as discussed in the Technical and Institutional Considerations section. However, most comparative studies did not systematically evaluate these predictors, limiting formal assessment of their impact on reported clearance rates. Efficacy in elderly populations was comparable to the two-stage procedure (15). Collectively, these data suggest that LCBDE provides equivalent or superior ductal clearance, particularly when performed in experienced centers with access to intraoperative cholangiography and choledochoscopy as discussed further below.

Complications and safety

Overall morbidity and mortality rates were low for both approaches, with absolute mortality typically under 1% (4,7,9). The pattern of complications differs: ERCP is more frequently associated with post-procedure pancreatitis, bleeding, and perforation, whereas LCBDE carries risks of bile leak and surgical-site infections (2,16,25).

Single-stage management is associated with lower overall morbidity, largely due to the avoidance of ERCP-related pancreatitis. Morbidity and mortality rates of approximately 7% and 0.2% for LCBDE compared with 13.5% and 0.5% for ERCP + LC have been reported (2). Pancreatitis rates are lower with LCBDE (0.7% vs. 6.0%), whereas rates of cholangitis and bleeding are similar (16).

Some data suggest a slightly higher incidence of intraoperative bleeding and bile leakage with LCBDE, reflecting the learning curve associated with choledochotomy and technical difficulties (25). Long-term complications were reported to be significantly lower after LCBDE (3.7% vs. 23.9%; P<0.05) (28). Importantly, most comparative studies did not uniformly report surgeon volume, emergency versus elective setting, or detailed technical approach, limiting the ability to determine whether complication rates were influenced by case selection or institutional experience.

It is also key to recognize that ERCP and LCBDE may serve complementary roles in managing complications. ERCP remains an effective salvage therapy for postoperative bile leaks or retained stones following LCBDE, while laparoscopic exploration has been demonstrated to be a safe and feasible option after failed endoscopic stone extraction (29). These bidirectional salvage pathways further support the overall safety and flexibility of a multidisciplinary approach.

Overall, both techniques are safe and effective, but LCBDE minimizes risks of post-ERCP pancreatitis and preserves sphincter function, resulting in comparable or lower morbidity without increased mortality (14).

Length of stay and recovery

Nearly all comparative studies demonstrate a shorter hospital stay after LCBDE, with patients typically discharged 1–3 days earlier than after two-staged ERCP + LC (3,5,6,11,17-19,23). In one multicenter study, mean time to discharge after first procedure was 55 hours following LCBDE versus 98 hours after ERCP + LC (24).

Although oral intake may resume slightly earlier after ERCP, total recovery time and return to normal activity remain equivalent (9). LCBDE is also associated with less postoperative inflammation, faster recovery, and fewer overall complications, supporting its efficiency as a single-stage strategy (15). Collectively, these findings confirm that LCBDE consistently reduces hospitalization without prolonging recovery.

Cost and resource utilization

Economic analyses consistently demonstrated lower costs for LCBDE compared with ERCP + LC. Reduced hospitalization, fewer anesthesia events, and elimination of a second procedure contribute to this difference. Reported total costs range from $4,422.26 vs. $7,812.21 to $46,685 vs. $60,537 in favor of LCBDE (11,16,17,19,23,25). Professional fees are also significantly lower for single-stage procedures ($4,820 vs. $6,139; P<0.001) (24).

These cost advantages were observed across diverse healthcare settings; however, absolute estimates are influenced by healthcare system structure, operating room cost allocation, endoscopy capacity, and institutional practice patterns. Therefore, while the direction of cost benefit consistently favors LCBDE in comparative analyses, the magnitude of cost differences may vary across healthcare environments. Once institutional expertise is established, LCBDE appears to offer a cost-efficient strategy without compromising clinical outcomes (5,20).

Technical and institutional considerations

Despite comparable or superior outcomes, LCBDE remains underutilized, with 75–88% of surgeons favoring an ERCP approach and fewer than 10% routinely performing LCBDE (11,13). The main barriers include limited access to choledochoscopy, lack of training, timely availability of an ERCP proceduralist, and inadequate institutional infrastructure, though most surveyed surgeons support broader adoption of LCBDE in their departments (84%) (13). These infrastructural limitations may include restricted access to fluoroscopic C-arm equipment for intraoperative cholangiography, competition for shared imaging resources across surgical services, and the need for coordinated operating room personnel familiar with bile duct exploration.

Preoperative ERCP should generally be reserved for severe cholangitis, biliary pancreatitis, or persistent jaundice (8). Success with LCBDE correlates with surgeon experience, institutional resources, and procedural volume (20,21,26). Reported learning curve thresholds vary considerably across studies, depending on analytic methodology and whether assessment is done at the individual surgeon or institutional level. A recent systematic review of learning curves in LCBDE demonstrated substantial heterogeneity, with pooled estimates suggesting approximately 79 cases required to overcome the learning curve, and higher thresholds reported when non-arbitrary or cumulative sum (CUSUM) methods were used (30). These findings suggest that learning curve stabilization is variable and context-dependent rather than defined by a uniform case number. Advanced laparoscopic suturing skill remains a recognized barrier to broader adoption of LCBDE, particularly when choledochotomy and primary duct closure are required. Emerging technologies such as three-dimensional laparoscopy and the use of barbed sutures may facilitate intracorporeal suturing and reduce technical difficulty, potentially lowering the learning threshold for surgeons performing transductal exploration (31).

Beyond surgeon experience, anatomical and technical factors play a central role in determining suitability for LCBDE. Successful transcystic or transductal exploration requires suitable biliary duct anatomy, including adequate cystic duct caliber to permit passage of a choledochoscope (32). The choice between transcystic exploration and choledochotomy is influenced by cystic duct diameter, ductal alignment, stone size, and stone burden. Additionally, variations in biliary anatomy, such as a tortuous cystic duct or periampullary diverticulum, may increase procedural complexity for either endoscopic or surgical management (25). Advances such as laparoscopic ultrasound, balloon sphincteroplasty, and disposable choledochoscopes are improving accessibility and efficiency (33-35). Because most comparative studies did not consistently report detailed anatomical selection criteria or specify the proportion of transcystic versus transductal approaches used, it is not possible to determine whether all ERCP + LC patients would have been technically appropriate candidates for single-stage exploration. This heterogeneity should be considered when interpreting comparative outcomes. In patients with altered upper gastrointestinal anatomy such as Roux-en-Y gastric bypass, standard ERCP is often not feasible and alternative approaches—including enteroscopy-assisted ERCP, laparoscopic-assisted transgastric ERCP, or percutaneous access—add operative time, complexity, and increased morbidity (36). In cases complicated by cholangitis, percutaneous transhepatic drainage may be required for urgent biliary decompression. Because LCBDE provides direct laparoscopic access to the biliary tree without the need for additional access procedures, it often represents the most efficient and practical strategy in this population.

These findings indicate that barriers to LCBDE adoption are largely educational and infrastructural rather than technical, and outcomes can equal or exceed ERCP when performed in appropriately equipped centers.

Patient satisfaction and quality of life

Although clinical outcomes dominate most comparative analyses, several studies have also evaluated patient-centered measures including satisfaction, acceptance, and postoperative quality of life. Across these studies, results generally favored the single-stage approach. One study utilizing the Surgical Satisfaction Questionnaire-8, a validated instrument designed to assess the postoperative recovery experience, at three months postoperatively demonstrated higher patient satisfaction and acceptance following LCBDE compared with the two-stage ERCP + LC (mean satisfaction scores 85.8 vs. 81.2; P<0.01) (16). Similarly, overall patient satisfaction and perceived treatment convenience were rated more favorably among those managed with LCBDE (5). In contrast, measures of postoperative quality of life and long-term acceptance were equivalent between groups, suggesting that once recovery is complete, overall well-being normalizes regardless of approach (24).

Taken together, these findings suggest that LCBDE provides at least equivalent, and often superior, patient satisfaction and treatment acceptance.

Strengths and limitations of this review

This review synthesizes evidence from comparative studies spanning over two decades, encompassing randomized trials, meta-analyses, and large cohort studies. The inclusion of contemporary evidence allows assessment of outcomes in the context of modern laparoscopic and endoscopic practice. By summarizing data across efficacy, safety, cost, and patient-reported metrics, the review captures a wide range of clinically relevant parameters applicable to modern practice.

The main strengths of this review include its comprehensive scope, representation of diverse study designs and populations, and integration of recent data reflecting current minimally invasive standards. The inclusion of both clinical and patient-centered outcomes enhances the contextual relevance of the evidence base.

Limitations include the narrative review methodology, which does not involve systematic literature retrieval or quantitative synthesis. The heterogeneity of study designs, outcome measures, and institutional experience introduces potential selection and reporting bias.

Additionally, data on long-term quality of life and functional recovery remain limited. Furthermore, although the LCBDE approach (transcystic vs. transcholedochal) was documented where available, most studies did not consistently stratify complication or learning curve outcomes by technique, limiting the ability to perform approach-specific subgroup analysis. In addition, this review focused on preoperative ERCP + LC and LCBDE, excluding hybrid or rendezvous procedures that are increasingly utilized and may alter comparative outcomes. These factors should be considered when interpreting the summarized findings.

Conclusions

Current evidence demonstrates that LCBDE is a safe and effective alternative to the traditional two-stage approach of preoperative ERCP followed by LC. Across multiple comparative studies, LCBDE achieves equivalent or superior ductal clearance, similar or lower morbidity, and shorter hospital stays at a reduced overall cost. LCBDE offers a practical advantage in patients with altered upper gastrointestinal anatomy, such as Roux-en-Y gastric bypass, where standard ERCP is not feasible and alternative techniques increase procedural complexity and morbidity. These findings support the role of single-stage management as a preferred strategy in appropriately selected patients when surgical expertise and resources are available.

However, institutional variability in training, equipment, and multidisciplinary coordination continues to influence adoption. Broader implementation of LCBDE will require enhanced surgeon training, improved access to choledochoscopy, and institutional protocols that support minimally invasive bile duct exploration. Future research should focus on standardizing outcome definitions, incorporating patient-reported metrics, and comparing LCBDE with rendezvous or other hybrid techniques to define optimal management pathways for choledocholithiasis.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-66/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-66/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-66/coif). The series “Laparoscopic and Endoscopic Management of Advanced Benign Biliary Pathologies” was commissioned by the editorial office without any funding or sponsorship. J.L.L. served as an unpaid Guest Editor of the series. J.L.L. is a consultant for Steris Endoscopy. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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