Single-stage versus two-stage management with postoperative ERCP of bile duct stones found at cholecystectomy: a population-based register study
Caroline Rajala, Christoffer Odensten, Michael Dahlberg, Gabriel Sandberg, Lars EnochssonAbstract
Introduction
While single-stage management of bile duct stones (BDS) during laparoscopic cholecystectomy (LC) is favoured, evidence comparing intraoperative methods with LC followed by postoperative endoscopic retrograde cholangiopancreatography (ERCP) is limited. Furthermore, the impact of hospital cholecystectomy volume on outcomes remains unclear.
Methods
This nationwide retrospective cohort study used GallRiks registry data (2011–2022) to evaluate patients with BDS detected via intraoperative cholangiography during LC. Single-stage and two-stage BDS management were compared regarding overall complications, unplanned re-ERCP, and bile duct injury. Hospitals were stratified by annual cholecystectomy volume (<100, 100–149, 150–200 and >200). Outcomes were assessed using univariable and multivariable regression analyses, adjusting for sex, age and ASA grade.
Results
Among 20 376 patients, 17 734 underwent single-stage and 2642 received two-stage management. Two-stage management was associated with an increased risk of overall complications (OR 1.47, 95% c.i. 1.32–1.63) and unplanned re-ERCP (OR 3.24, 95% c.i. 2.71–3.88). Using the <100 category as the reference (OR 1.00), the consecutively higher-volume categories demonstrated a decreased risk of overall complications (OR 0.75, 95% c.i. 0.63–0.90; OR 0.73, 95% c.i. 0.61–0.86; OR 0.79, 95% c.i. 0.68–0.93, respectively). Only the highest-volume category exhibited a significantly lower risk or re-ERCP compared with the reference group (OR 0.68, 95% c.i. 0.51–0.92). There was no difference in the risk of bile duct injury between single-stage and two-stage management, nor between the hospital categories.
Discussion
Single-stage management of BDS lowers complications and re-ERCP risks compared with two-stage management, without increasing bile duct injuries. Additionally, management at hospitals performing ≥100 cholecystectomies annually improve outcomes.