There are various therapeutic options such as ERCP, LCBDE or open CBD exploration for the management of common gallbladder stones and CBD stones. ERCP and LCBDE are the two most ideal of mini-invasive strategies, which are widely used in patients with cholelithiasis.[1516] Although both endoscopic and laparoscopic techniques have evolved considerably with refinement in equipment and technique, the optimal treatment for concomitant gallbladder stones and CBD stones is still uncertain.[917]

The purpose of this study was to compare the efficacy, safety and the surgical outcomes of LC + LCBDE with LC + ERCP/EST and determine the most appropriate approach for patients with cholelithiasis. The meta-analysis showed that no significant difference was noted between the two groups in terms of CBD stone clearance (RR: 1.06; 95% CI: 0.99–1.14; P = 0.12), post-operative morbidity (RR: 1.03; 95% CI: 0.79–1.34; P = 0.81), mortality (RR: 0.30; 95% CI: 0.06–1.41; P = 0.13), retained stone (RR: 0.91; 95% CI: 0.57–1.47; P = 0.71), conversion to other procedures (RR: 0.80; 95% CI: 0.55–1.16; P = 0.23), length of hospital stay (WMD: 1.24, 95% CI: 3.57–1.09, P = 0.30), total operating time (WMD: 25.42, 95% CI: 22.38–73.22, P = 0.30).

ERCP with the EST has become the most common intervention for CBD stones after its introduction in the 1970s.[12] The overall success rate of ERCP is well established at about 95% in experienced hands. ERCP avoided the complexities of laparoscopic choledochotomy and potential problems from T-tube drainage (TTD), but underwent two procedures. ERCP has some but not at all rare failure-related factors, such as post-surgical gastrointestinal anatomic variations (Billroth II), duodenal diverticulum, embedded stones in the ampulla, intrahepatic bile duct stones and CBD strictures.[1218]

There was a gap period between ERCP and LC, which may cause CBDS recurrences. The time interval between endoscopic papillotomy and LC is controversial. de Vries et al.[19] have shown higher conversion rate when the cholecystectomy was done more than 2 weeks after EST. Allen et al.[20] and Donkervoort et al.[21] also reported greater difficulty and higher complication rate with LC after ERCP, due to the inflammation and fibrosis in and around Calot's triangle after ERCP. However, for indications of severe cholangitis, severe biliary pancreatitis and possibly persistent obstructive jaundice ERCP are irreplaceable because it can release biliary obstruction in a timely fashion.

LCBDE has the advantage of being a minimal access procedure, and it is a one-step procedure compared with ERCP. The single-stage treatment provided a single intervention which dealt with all the problems in one step in most patients. With advances in technology and laparoscopic techniques primary LCBDE currently is challenging the present standard of ERCP followed by LC for patients with gallbladder and CBD stones. Since the first experiences reported in 1991, this procedure has been performed together with new technologies and has become the star for laparoscopic management of the CBD stones over the past few decades. LCBDE by an experienced laparoscopic surgeon is currently considered as effective as ERCP.[1022] Sgourakis and Karaliotas[5] showed equivalent clearance rate between single-stage and two-stage procedures. Rogers et al.[9] in their study also found similar clearance rates. Noble et al.[7] reported better success rates for laparoscopic than endoscopic, even for high-risk patients, with no increase in the complication rate or hospital stay. In this meta-analysis, we found that there was no statistically significant difference between one-single group and two-stage group about the CBD stone clearance. However, the success rate in single-stage group is higher than two-stage group.

The post-operative morbidity was similar between the single stage (14.20%, 91 of 641) and two stage (13.93%, 90 of 646), with no statistically significant. LC-ERCP requires two periods of anaesthesia and occasionally two hospital admissions. In addition, ERCP can also be followed by short-term complications,[2324] including pancreatitis, bleeding, perforation and cholangitis. Third, the sphincter of Oddi is destroyed by sphincterotomy, resulting in permanent loss of the biliary sphincter function and damage to the sphincter barrier which prevents duodenobiliary reflux.[12] Reflux from the duodenum into the bile duct is associated with a high rate of recurrent cholangitis following sphoncterotomy[25] and this can lead to CBD stone formation, and also increased the risk of cholangiocarcinoma related to post-sphincterotomy cholangitis could be found in the long term.[2627] The most common complication for LCBDE is bile leak, which is associate with T-tube usage. TTD has been routinely adopted after choledochotomy, not only for post-operative bile duct decompression to decrease biliary complications, such as biliary stricture but also for post-operative cholangiography to detect any residual stones and provide access for trans-T-tube tract stone removal.[2829] In addition, the bile drainage tube must remain in situ for approximately 2 weeks before removal, and this can cause some discomfort. Nevertheless, according to a recent meta-analysis,[30] primary closure might be as effective as TTD in the prevention of post-operative complications after choledochotomy. Consequently, it seems that LCBDE is a commendable alternative to the use of ERCP/EST.

Regarding to retain stone rate, conversion to other procedure, mortality, the total operative time and length of hospital stay there were similar between the two therapies with no significant differences.

The limitations of this meta-analysis must be taken into consideration when interpreting its results. First, there was heterogeneity among the include studies, However, one should not be surprising given the variation in the characteristics of populations (age, female/male, stone number, stone size), time intervention between endoscopic papillotomy and LC, laparoscope device and operator experience between the 2 approaches. All these factors contributed to the heterogeneity and had potential impacts on our results. Although we used the random-effects model instead of the fixed-effects model, it was impossible to overcome any potential bias. Second, not all studies provided data on the total operative time and length of hospital time. Third, the restriction of only including studies published in English was another possible limitation. Finally, it is important to bear in mind publication bias, particularly in meta-analysis based on published studies.