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ORIGINAL ARTICLE

A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones Hong-Yi Zhu 1, Ming Xu 1, Huo-Jian Shen , Chao Yang , Fu Li , Ke-wei Li , Wei-Jin Shi , Fu Ji ∗ Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medcine, Shanghai Jiao Tong University, Shanghai 200127, China

Summary Objective: To conduct a randomized controlled trial (RCT) meta-analysis to evaluate the safety and effectiveness of single-stage [laparoscopic cholecystectomy (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage management [preoperative endoscopic retrograde cholangiopancreatography (ERCP) + LC] for concomitant gallstones and common bile duct stones. Methods: RCTs that met the inclusion criteria for data extraction were identified from electronic databases (PubMed, Embase, Science Citation Index, and the Cochrane Library) up to August 2014. The relevant congressional proceedings were also searched. The primary outcomes were stone clearance from the common bile duct, postoperative morbidity and mortality. The secondary outcomes were conversion to other procedures, length of hospital stay, total operative time, and hospitalization charges. The outcomes were calculated as odds ratios (ORs) with 95% confidence intervals (CIs) using RevMan 5.2. Results: Eight RCTs, which included 1130 patients, were identified for analysis in our study. The meta-analysis revealed that the common bile duct stone clearance rate in the single-stage group was higher (OR = 1.56, 95% CI: 1.05 to 2.33, P = 0.03). The lengths of hospital stay (MD = −1.02, 95% CI: −1.99 to −0.04, P = 0.04) and total operative times (MD = −16.78, 95% CI: −27.55 to −6.01, P = 0.002) were also shorter in the single-stage group. There was no statistically significant difference between the two groups regarding postoperative morbidity (OR = 1.12, 95% CI: 0.79 to 1.59, P = 0.52), mortality (OR = 0.29, 95% CI: 0.06 to 1.41, P = 0.13) and conversion to other procedures (OR = 0.82, 95% CI: 0.37 to 1.82, P = 0.62).



Corresponding author at: Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No. 160 Pujian Road, Shanghai 200127, China. Tel.: +0086 13901903543; fax: +0086 21 68383773. E-mail address: [email protected] (F. Ji). 1 These authors contributed equally to this article. http://dx.doi.org/10.1016/j.clinre.2015.02.002 2210-7401/© 2015 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

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Conclusion: Single- and two-stage management for cholecysto-choledocholithiasis had similar mortality and complication rates; however, the single-stage strategy was better in terms of stone clearance, hospital stay and total operative time. © 2015 Elsevier Masson SAS. All rights reserved.

Introduction Common bile duct stones (CBDS) occur in approximately 8%—20% [1—3] of cholelithiasis patients. There are two broad options for management of patients with concomitant gallstones and choledocholithiasis, which include a single-stage strategy that comprises laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) or a two-stage approach consisting of LC and pre- or postoperative ERCP [4]. Surgeons tend to clear the common bile duct (CBD) of stones preoperatively by ERCP because further surgery is needed if postoperative ERCP fails [5]. ERCP followed by LC has been the treatment of choice for concomitant gallstones and CBDS for decades. However, the major shortcoming of ERCP is that it requires the two-stage approach (laparoscopic cholecystectomy and preoperative/postoperative ERCP), which can not only cause life-threatening complications, including bleeding, perforation and pancreatitis [6,7], but also can lead to disruption of the intact sphincter of Oddi [8]. Meanwhile, single-stage concomitant CBD and gallbladder stone management is gaining popularity as the laparoscopic technique matures and surgeons attain experience with the technique. It avoids the morbidity and mortality associated with ERCP as well as the need for multiple procedures; however, the main drawback of single-stage management is that the common bile duct is traditionally closed with T-tube drainage after LCBDE and patients may have to carry the drain for several weeks before removal. This increases the psychological pressure and difficulty in postoperative nursing of patients [9,10]. Currently, it is still uncertain whether the two-stage management approach is better than or at least equivalent to the single-stage surgical strategy for cholecysto-choledocholithiasis [11,12]. A previous meta-analysis conducted in 2012 [13] that compared the single-stage and two-stage approaches for the management of concomitant gallstones and CBDS concluded that the two groups were equally effective but that the two-stage approach contained both preoperative and postoperative ERCP. Since then, three randomized trials have been published; therefore, we conducted this meta-analysis of all of the randomized controlled trials (RCTs) to evaluate the clinical safety and effectiveness of the two-stage (ERCP + LC) versus the single-stage (LC + LCBDE) management approaches for concomitant gallstones and CBDS.

Materials and methods Searching strategy We searched databases, including PubMed, Embase, the Science Citation Index, and the Cochrane Library, up to August

2014 to identify all of the related published RCTs. The keywords used in the searches were as follows: LC, LCBDE, ERCP, EST, gallbladder stones, and common bile duct stones. The language was restricted to English only. The citations within the reference lists of the articles were searched manually to identify any additional eligible studies.

Inclusion and exclusion criteria The studies that were published up to and including August 2014 were considered eligible if they met the following inclusion criteria: • study design: RCTs; • population: patients with proven or suspected CBDS before LC or those with gallstones that were found to have CBDS at LC by intraoperative cholangiography; • intervention: preoperative ERCP/EST + LC vs. LC + LCBDE. Abstracts from conferences and full texts without raw data that was available for retrieval, duplicate publications, letters, non-randomized trials, retrospective analyses and reviews were excluded. If publications reported on the same study population, then the most informative article was included.

Study quality assessment The literature quality was independently assessed by two authors (Hong-Yi Zhu and Ming Xu) by utilizing the modified Jadad Scale. Scores of 0 to 7 were allocated to each study. Studies with a score of 4 or more were defined as high-quality studies. Those with a score of 3 or less were defined as low quality.

Outcomes of interest and definitions The primary outcomes were stone clearance from the CBD, postoperative morbidity, and mortality, while the secondary outcomes were conversion to other procedures, overall hospital stay, and total operative time. Successful stone clearance was defined as the CBDS removal with the intended treatment modality via the planned procedure, only once. The overall postoperative morbidity consisted of surgical and nonsurgical complications, such as bleeding, perforation, cholangitis, ileus, bile leak, fistulas, surgical-site infections, myocardial infarctions and pulmonary embolisms, all of which had nothing to do with the operation. Mortality was defined as postoperative death before discharge or within 30 postoperative days. Conversion to other procedures was defined as any case in which stones from the CBD were not successfully extracted or other

Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

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Figure 1

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A flow chart of the selection criteria of the studies eligible for data extraction and analysis.

scenarios that resulted in converting the planned procedure into another procedure.

Results Search results and reporting quality

Data extraction and statistical analysis Two reviewers (Hong-Yi Zhu and Ming Xu) independently abstracted the relevant information from each eligible article using a standardized form. Information regarding the characteristics of the study population, authors, publication year, study period, country, sample size, interventions, outcome details of the surgical techniques used, and the relevant outcomes were recorded. Disagreements between reviewers regarding data abstraction were resolved through a discussion. Statistical analysis of dichotomous variables was performed using the odds ratio (OR) as the summary statistic, while continuous variables were analysed using the weighted mean difference (MD). For both variables, 95% confidence intervals (CIs) were reported. Heterogeneity was assessed using the I2 statistic. The heterogeneity among the studies was evaluated using the Mantel-Haenszel Chi2 test, with its significance set at P < 0.1, and the extent of inconsistency was assessed with the I2 statistic [14]. I2 values of < 25% were defined as low heterogeneity. Those between 25% and 50% were defined as having moderate heterogeneity and those > 50% were defined as having high heterogeneity. In cases that lacked heterogeneity, fixed-effects or random-effects models were used for the meta-analysis. The estimates of the means and SDs were required to calculate the CIs for continuous data. For these tests, a P-value < 0.05 was considered statistically significant. The analyses were conducted with Review Manager Version RevMan 5.2.

According to the search strategy described previously, a total of 1076 citations were obtained for title and abstract review (Fig. 1). Of the 1076 citations, 118 duplicates were removed with the Endnote X5 software, and 926 irrelevant studies were excluded by scanning the titles and abstracts. Full texts of the remaining 32 eligible studies were retrieved for review. Of the 32 full text articles, 23 non-randomized trials and one article [15] that contained a repeat study population were excluded. The reviewers were in perfect agreement in selecting the eight utilized studies, by using the stated eligibility criteria. Eventually, eight RCTs [16—23] were considered to be suitable for the final meta-analysis. The characteristics, quality assessment, and outcomes for the included studies are summarized in Tables 1 and 2.

Meta-analysis results Stone clearance from the CBD Stone clearance from the CBD was achieved in 90.2% (413 of 458) of patients in the single-stage (LC + LCBDE) group and in 85.7% (396 of 462) of patients in the two-stage (ERCP + LC) group. The difference between the two groups was statistically significant (OR = 1.56, 95% CI: 1.05 to 2.33, P = 0.03). The heterogeneity among the studies was low (Chi2 = 12.07, P = 0.1, I2 = 42%) (Fig. 2).

Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

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The characteristics and quality assessment of the included studies. Country

Study period

Comparison

Cases

Sex (M/F)

Age (year)

Follow-up period (months)

Jadad scale score

Bansal et al. [16] 2014

India

2009—2012

LC + LCBDE ERCP + LC

84 84

23/61 34/50

45.1 ± 15.1 43 ± 13.7

7.9 ± 3.4 8.5 ± 4

5

Ding et al. [17] 2014

China

2002—2005

LC + LCBDE ERCP + LC

110 111

53/57 53/58

58.42 ± 7.21 57.53 ± 6.31

96—120

4

Koc et al. [18] 2013

Turkey

2008—2010

LC + LCBDE ERCP + LC

57 54

20/37 18/36

51.56 ± 16.6 54.96 ± 617.9

Not mentioned

2

Bansal et al. [19] 2010

India

2007—2008

LC + LCBDE ERCP + LC

15 15

4/11 5/10

47.1 (34—72) 39.07 (23—64)

Not mentioned

4

Rogers et al. [20] 2010

United Kingdom

1997—2003

LC + LCBDE ERCP + LC

57 55

17/40 16/39

39.9 ± 1.9 44.6 ± 1.9

> 24

6

Noble et al. [21] 2009

United Kingdom

2000—2006

LC + LCBDE ERCP + LC

44 47

16/28 22/25

75.9 (70.0—80.8) 74.3 (70.0—78.9)

> 12

4

Sgourakis et al. [23] 2002

Greece

1997—2000

LC + LCBDE ERCP + LC

36 42

15/21 17/25

43—88 46—89

22.36

4

Cuschiei et al. [22] 1999

Scotland

1994—1997

LC + LCBDE ERCP + LC

150 150

60/90 42/108

19—88 18—89

Not mentioned

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Study

M: male; F: female; LCBDE: laparoscopic common bile duct exploration; ERCP: endoscopic retrograde cholangiopancreatography.

H.-Y. Zhu et al.

Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

Table 1

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Table 2 Outcomes of the 8 included RCTs (laparoscopic cholecystectomy + laparoscopic common bile duct exploration) versus (endoscopic retrograde cholangiopancreatography/endoscopic sphincterotomy + laparoscopic cholecystectomy). Study

Stone clearance from CBD (%)

Mortality (%)

Postoperative morbidity (%)

Conversion to other procedures (%)

Total operating time (min) (SD or range)

Hospital stay (median or mean, days)

Bansal et al. [16] 2014

88.1 vs. 79.8

0 vs. 3.6

23.8 vs. 22.6

8.3 vs. 3.6

Not mentioned

4.6 vs. 5.3

Ding et al. [17] 2014

93.6 vs. 94.6

0 vs. 0

3.6 vs. 5.4

2.7 vs. 0.9

Not mentioned

Not mentioned

Koc et al. [18] 2013

96.5 vs. 94.5

0 vs. 0

7.0 vs. 11.1

0 vs. 1.9

93.47 (32.06) vs. 113.33 (36.07)

3 vs. 6 (median)

Bansal et al. [19] 2010

93.3 vs. 86.7

0 vs. 0

13.3 vs. 15.3

6.7 vs. 15.4

? vs. 153 (120—240)

4.2 vs. 4 (mean)

Rogers et al. [20] 2010

88.2 vs. 96.8

0 vs. 0

10.5 vs. 9.1

3.5 vs. 1.8

174 (67) vs. 183 (39)

5.3 vs. 6.6 (mean)

Noble et al. [21] 2009

100 vs. 55.6

0 vs. 0

43.2 vs. 29.8

9.1 vs. 42.6

Not mentioned

5 vs. 3 (median)

Sgourakis et al. [23] 2002

85.7 vs. 84.3

0 vs. 3.1

17.9 vs. 18.8

14.3 vs. 15.6

90 (70—310) vs. 105 (60—255)

7.4 vs. 9 (median)

Cuschieri et al. [22] 1999

82.6 vs. 83.7

0.8 vs. 1.5

15.8 vs. 12.5

15 vs. 14.7

Not mentioned

6 vs. 9 (median)

RCTs: randomized controlled trials; CBD: common bile duct.

Mortality The mortality rate was 1/245 (0.4%) in the single-stage management group and 6/252 (2.3%) in the two-stage management group. No significant difference between the two groups was observed; and there was no significant heterogeneity between the trials (Chi2 = 0.47, P = 0.79, I2 = 0%) (Fig. 3).

approaches regarding pancreatitis (OR = 0.23, 95% CI: 0.08 to 0.69, P = 0.008) and bile leak (OR = 5.27, 95% CI: 2.06 to 13.47, P = 0.0005). There were less pancreatitis cases in the single-stage group (2/428) than the two-stage group (15/429); however, there were many more bile leak cases in the single-stage group (25/310 vs. 4/309) (Fig. 4).

Postoperative morbidity The total patient morbidity rate was 81/528 (15.3%) in the single-stage management group and 75/529 (14.2%) in the two-stage management group. No significant difference was observed between the two groups (OR = 1.12, 95% CI: 0.79 to 1.59, P = 0.52). However, there was a statistically significant difference between the single-stage and two-stage

Conversions to other procedures There was no statistically significant difference between the two groups regarding the conversion rate (OR = 0.82, 95% CI: 0.37 to 1.82, P = 0.62). Significant heterogeneity was revealed in the trials (Chi2 = 13.83, P = 0.03, I2 = 57%), and significant heterogeneity was present in the trials (Chi2 = 14.36, P = 0.05, I2 = 51%) (Fig. 5).

Figure 2 Meta-analysis of the single-stage [laparoscopic common (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage (ERCP + LC) approach regarding common bile ducts (CBDs) clearance (fixed-effects model).

Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

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Figure 3 The single-stage (LC + LCBDE) vs. two-stage [endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic common (LC)] approach regarding mortality (fixed-effects model).

The total operative times There were only two trials [18,20] that included information regarding total operative time means and SDs. The pooled estimates of these two studies revealed a statistically significant difference between the two groups (MD = −16.78, 95% CI: −27.55 to −6.01, P = 0.002) (Fig. 6). The lengths of hospital stay Only two studies reported length of hospital stay means and SDs. The length of hospital stay was significantly shorter in the single-stage group than in the two-stage group (MD = −1.02, 95% CI: −1.99 to −0.04, P = 0.04) (Fig. 7).

Although the available studies were less, based on the evidence from Table 2, the single-stage group had the advantage of shorter hospital stays. Sensitivity analysis and publication bias Each study was evaluated regarding the influence of individual studies on the meta-analysis of the outcomes in order to evaluate the robustness of the results. The results showed that the pooled estimates before or after the deletion of any single study were generally similar in all but the CBDS clearance outcome. When Noble et al.’s study [21] was excluded from the CBDS clearance outcome analysis, it caused there

Figure 4 The single-stage [laparoscopic common (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage [endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic common (LC)] approach regarding the total and major morbidities (fixed-effects model).

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Figure 5 The single-stage [laparoscopic common (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage [endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic common (LC)] approach regarding conversion to other procedures (random-effects model).

Figure 6 The single-stage [laparoscopic common (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage [endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic common (LC)] approach regarding total operating times (fixed-effects model).

Figure 7 The single-stage [laparoscopic common (LC) + laparoscopic common bile duct exploration (LCBDE)] vs. two-stage [endoscopic retrograde cholangiopancreatography (ERCP) + laparoscopic common (LC)] approach regarding the lengths of hospital stay (fixed-effects model).

to be no statistically significant between the two groups. Publication bias was not assessed because the number of studies was less than 10.

Discussion The optimal treatment for concomitant gallstones and CBDS is still uncertain, while endoscopic retrograde cholangiography followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide. With the development of laparoscopic equipment and techniques, LCBDE has emerged as the favourable choice in the hands of experienced laparoscopic surgeons since it was first reported in 1991 [24]. Additionally in 2008, the British Society of Gastroenterologists encouraged surgeons to train in LCBDE [25]. ERCP + LC requires two separate procedures, and the two procedures are often performed days or weeks apart from each other. Thus, the patient will require a prolonged hospital stay during the wait or will be admitted to hospital twice for each individual procedure. Furthermore, the patient is exposed to the risks of anaesthesia/sedation twice, and

there is a risk that their clinical condition could deteriorate in the time between the two procedures. LCBDE + LC, however, is performed as a single procedure and usually results in the patient having a shorter total hospital stay duration (because multiple or prolonged admissions are not necessary). Additionally, the patient is only exposed to anaesthesia once and has their condition treated definitively in one procedure. Thus, the Guideline Development Group (GDG) [26] agreed that, in principle, LCBDE + LC is superior to ERCP + LC. Although LCBDE + LC seems to be a good treatment option for CBDS, the procedure remains limited to a long and significant learning curve to master intracorporeal suturing and knotting as well as choledochoscopy. Moreover, because the expertise in surgical bile duct exploration is diminishing significantly, many surgeons remain fearful of conducting LCBDE [27]; therefore, the treatment strategy is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another [28]. This meta-analysis indicated that the single-stage approach (LC + LCBDE) achieved greater CBDS clearance than the two-stage (ERCP + LC) approach. Additionally, the

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length of hospital stay and total operative time durations were shorter in the single-stage group; however, there was no statistical significance between the two groups in terms of postoperative morbidity, mortality, and conversions to other procedures. The stone clearance rate was statistically higher in the single-stage (LC + LCBDE) group (90.2%, 413 of 458) than in the two-stage (ERCP + LC) group (85.7%, 396 of 462). One possible reason for this was that with increasing surgical experience and laparoscopic equipment improvements, the operation exploration and calculus scopes are removed, which more widely enables access to patients with multiple, large, and impacted CBDS [12,29,30]. Even if the stone is obstructing the sphincter of Oddi, then surgeons can use laser lithotripsy to break the stone and remove it. Another possible reason is that a part of CBDS involves the gallbladder. As far as the two-stage group was concerned, there was a gap time period between ERCP and LC, which may cause CBDS recurrences. Additionally, ERCP can lead to long-term complications, such as sphincter of Oddi disruption, thereby causing injury to the barrier function of the sphincter that prevents duodenobiliary reflux [32]. Reflux from the duodenum into the bile duct is associated with an increased bacterobilia incidence. This can lead to CBDS formation [33]. Moreover, sometimes pre- (or post-) operative ERCP fails in stone removal because of retrograde intubation failure in some cases, such as duodenal diverticulum and anomalous pancreaticobiliary ductal junction (APBJ). Therefore, the CBDS recurrences seem to be high in the two-stage group [17,34—36] after long-term follow-up periods. The mortality, postoperative morbidity and the conversion to other procedure rates were similar between the two groups with no statistically significant differences. However, the mortality rate was less in the single-stage management group (1/245, 0.4%) than in the two-stage management group (6/252, 2.3%). The 4 deaths in the two-stage management group were due to ERCP-related complications. Pancreatitis was observed more often in the two-stage group (OR = 0.23, 95% CI: 0.08 to 0.69, P = 0.008), which gave rise to a significant risk of death [31]. Although the number of bile leak cases was much higher in the single-stage group, it was transient in most patients and did not require any further intervention. However, T-tube drainage (TTD) has been routinely adopted after choledochotomy, not only for postoperative bile duct decompression to decrease biliary complications, such as bile leak or biliary stricture, but also for postoperative cholangiography to detect any residual stones and provide access for trans-T-tube tract stone removal [37,38]. Acceptance of LCBDE in most hospitals is far off due to its steep learning curve, especially when a T-tube has to be used [28]. Nevertheless, T-tube usage is associated with complications, such as postoperative bile leakage [5] and patient inconvenience, because it takes several weeks before the removal occurs, which increases the psychological pressure on the patients [39]. Thus, primary CBD closure has been shown to be a better alternative. Primary closure compared with T-tube drainage is safe and effective [40,41]. It seems that preoperative ERCP could be reserved for indications of severe cholangitis, severe biliary pancreatitis and possibly persistent obstructive jaundice. In regards to other cases where CBDS are suspected, laparoscopic cholecystectomy with LCBDE either by the transcystic

approach or by anterior choledochotomy may be utilized; however, the former is not always feasible in circumstances when the stones are too great in number or size and a cystic duct is too small in diameter or is implanted too low [42]. Although only two studies reported the length of hospital stay durations in the form of means and the SDs, we found a statistically significant difference in the length of hospital stays between the two groups, based on the evidence from Table 2. The hospitalization charges for the single-stage (LC + LCBDE) management approach were lower than the two-stage (LC + ERCP/EST) management approach in Bansal et al.’s study [16], which was due to the shorter lengths of hospital stay. Topal et al, in 2010 [43], concluded that hospitalization costs were significantly reduced for the onestage procedure (P < 0.0001). The total operating time was statistically significantly different between the two groups, whereby the total operation times were shorter in the singlestage (LC + LCBDE) management group. This meta-analysis has some limitations that should be taken into account when considering the results. First, by sensitivity analysis, there was one study [21] that had a great influence on CBDS clearance. There was no statistically significant between the two groups regarding CBDS clearance and no heterogeneity between the trials when that single study was excluded. One possible reason for this was that they abandoned the endoscopic route earlier in 6 patients who had multiple and larger stones detected in the CBD. Second, the intervention was different, whereby the choice between whether primary duct closures or TTDs were utilized after LCBDE was not uniform. In the two-stage group, the time interval between ERCP and LC was different. Specifically, early LC (within 72 hours) appears to be safe and might prevent the majority of biliary events [44]. Third, the patient numbers in some studies were small, which gave these analyses lower power. In conclusion, the single-stage (LC + LCBDE) management approach treats both gallstones and CBDS in a single-stage and is cost-effective with shorter hospital stays, and it may achieve a higher CBDS clearance rate than the two-stage (ERCP + LC) approach when an experienced laparoscopic surgeon utilizes it. LCBDE is a safe and effective treatment option for concomitant gallstones and CBDS in terms of long-term and short-term outcomes because it avoids the morbidity and mortality associated with ERCP and maintains the integrity of the sphincter of Oddi. With more refinement in equipment and technique, it is possible that LCBDE may become the gold standard for stones treatment. Certainly, ERCP is irreplaceable because it can release biliary obstructions in acute suppurative obstructive cholangitis patients in a timely fashion, which causes the patients to tolerate the surgery more easily.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

References [1] Ko CW, Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc 2002;56(6 Suppl.):S165—9.

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Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

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Please cite this article in press as: Zhu H-Y, et al. A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.02.002

A meta-analysis of single-stage versus two-stage management for concomitant gallstones and common bile duct stones.

To conduct a randomized controlled trial (RCT) meta-analysis to evaluate the safety and effectiveness of single-stage [laparoscopic cholecystectomy (L...
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