Cochrane Summaries

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Surgical versus endoscopic treatment of bile duct stones

Dasari BVM, Tan C, Gurusamy K, Martin DJ, Kirk G, McKie L, Diamond T, Taylor MA
Published Online: 
3 September 2013

Gallstones are a common problem in the general population and commonly cause problems with pain (biliary colic) and gallbladder infections (acute cholecystitis). Gallstones can sometimes migrate out of the gallbladder and become trapped in the tube between the gallbladder and the small bowel (common bile duct). Here, they obstruct the flow of bile from the liver and gallbladder into the small bowel and cause pain, jaundice (yellowish discolouration of the eyes, dark urine, and pale stools), and sometimes severe infections of the bile (cholangitis). Between 10% and 18% of people undergoing cholecystectomy for gallstones have common bile duct stones.

Treatment involves removal of the gallbladder as well as the gallstones from this tube. There are several methods to achieve this. Surgery is performed to remove the gallbladder. In the past, this was performed through a single large incision through the abdomen (open cholecystectomy). Newer keyhole techniques (laparoscopic surgery) are now the most common methods of removal of the gallbladder. Removal of the trapped gallstones in the common bile duct can be performed at the same time as the open or keyhole surgery. Alternatively, an endoscope (a narrow flexible tube equipped with a camera) is inserted through the mouth and into the small bowel to allow removal of the trapped gallstones from the common bile duct. This procedure can be performed before, during, and after the surgery to remove the gallbladder. This systematic review attempts to answer the question of the safest and most effective method to remove these trapped gallstones (in terms of open surgery or laparoscopic surgery compared with endoscopic removal), whether removal of the common bile duct stones should be performed during surgery to remove the gallbladder as a single-stage treatment or as a separate treatment before or after surgery (two-stage treatment).

Review questions
We analysed results from randomised clinical trials in the literature to assess the benefits and harms of these procedures

Quality of evidence
We identified a total of 16 trials including 1758 participants. All the trials were at high risk of bias (defects in study design which may result in overestimation of benefits or underestimation of harms). Overall the quality of the evidence is moderate because of the risk of systematic errors or bias (defects in study design) and random errors (insufficient number of participants were included in the trials) which can result in wrong conclusions.

Key results
Our analysis suggests open surgery to remove the gallbladder and trapped gallstones appears to be as safe as endoscopy and may even be more successful than the endoscopic technique in clearing the duct stones. Keyhole (laparoscopic) surgery to remove the gallbladder and trapped gallstones appears to be as safe as and as effective as the endoscopic technique. More randomised clinical trials conducted with low risks of systematic errors (trials) and low risks of random errors (play of chances) are required to confirm or refute the present findings.