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<h5 class="section-title" id="d3631509e296">Question</h5>
<p id="d3631509e298">What technique is best for surgical management of gallstone disease
with biliary duct
calculi?
</p>
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<h5 class="section-title" id="d3631509e301">Findings</h5>
<p id="d3631509e303">In this systematic review and network meta-analysis of 20 randomized
clinical trials
that included 2489 unique patients and 4 surgical techniques combining laparoscopic
cholecystectomy with a second technique, the rendezvous approach (laparoscopic cholecystectomy
plus intraoperative cholangiopancreatography) was associated with the highest rates
of safety and success compared with the other approaches.
</p>
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<h5 class="section-title" id="d3631509e306">Meaning</h5>
<p id="d3631509e308">The rendezvous approach should be the first choice for patients
with gallstone disease
and biliary duct calculi.
</p>
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<h5 class="section-title" id="d3631509e312">Importance</h5>
<p id="d3631509e314">Several techniques are used for surgical treatment of gallstone
disease with biliary
duct calculi, but the safety and efficacy of these approaches have not been compared.
</p>
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<h5 class="section-title" id="d3631509e317">Objectives</h5>
<p id="d3631509e319">To compare the efficacy and safety of 4 surgical approaches to
gallstone disease with
biliary duct calculi.
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<h5 class="section-title" id="d3631509e322">Data Sources</h5>
<p id="d3631509e324">MEDLINE, Scopus, and ISI-Web of Science databases, articles published
between 1950
and 2017 and searched from August 12, 2017, to September 14, 2017. Search terms used
were
<i>LCBDE</i>,
<i>LC</i>,
<i>preoperative</i>,
<i>ERCP</i>,
<i>postoperative</i>,
<i>period</i>,
<i>cholangiopancreatography</i>,
<i>endoscopic</i>,
<i>retrograde</i>,
<i>rendezvous</i>,
<i>intraoperative</i>,
<i>one-stage</i>,
<i>two-stage</i>,
<i>single-stage</i>,
<i>gallstone</i>,
<i>gallstones</i>,
<i>calculi</i>,
<i>stone</i>,
<i>therapy</i>,
<i>treatment</i>,
<i>therapeutics</i>,
<i>surgery</i>,
<i>surgical</i>,
<i>procedures</i>,
<i>clinical trials</i> as topic,
<i>random</i>, and
<i>allocation</i> in several logical combinations.
</p>
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<h5 class="section-title" id="d3631509e412">Study Selection</h5>
<p id="d3631509e414">Randomized clinical trials comparing at least 2 of the following
strategies: preoperative
endoscopic retrograde cholangiopancreatography (PreERCP) plus laparoscopic cholecystectomy
(LC); LC with laparoscopic common bile duct exploration (LCDBE); LC plus intraoperative
endoscopic retrograde cholangiopancreatography (IntraERCP); and LC plus postoperative
ERCP (PostERCP).
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<h5 class="section-title" id="d3631509e417">Data Extraction and Synthesis</h5>
<p id="d3631509e419">A frequentist random-effects network meta-analysis was performed.
The surface under
the cumulative ranking curve (SUCRA) was used to show the probability that each approach
would be the best for each outcome.
</p>
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<h5 class="section-title" id="d3631509e422">Main Outcomes and Measures</h5>
<p id="d3631509e424">Primary outcomes were the safety to efficacy ratio using overall
mortality and morbidity
rates as the main indicators of safety and the success rate as an indicator of efficacy.
Secondary outcomes were acute pancreatitis, biliary leak, overall bleeding, operative
time, length of hospital stay, total cost, and readmission rate.
</p>
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<h5 class="section-title" id="d3631509e427">Results</h5>
<p id="d3631509e429">The 20 trials comprised 2489 patients (and 2489 procedures).
Laparoscopic cholecystectomy
plus IntraERCP had the highest probability of being the most successful (SUCRA, 87.2%)
and safest (SUCRA, 69.7%) with respect to morbidity. All approaches had similar results
regarding overall mortality. Laparoscopic cholecystectomy plus LCBDE was the most
successful for avoiding overall bleeding (SUCRA, 83.3%) and for the shortest operative
time (SUCRA, 90.2%) and least total cost (SUCRA, 98.9%). Laparoscopic cholecystectomy
plus IntraERCP was the best approach for length of hospital stay (SUCRA, 92.7%). Inconsistency
was found in operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66;
<i>P</i> = .02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21;
<i>P</i> = .04). Heterogeneity was observed for success rate (τ, 0.8), operative time
(τ,
>1), length of stay (τ, >1), and total cost (τ, >1).
</p>
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<h5 class="section-title" id="d3631509e438">Conclusions and Relevance</h5>
<p id="d3631509e440">The combined LC and IntraERCP approach had the greatest odds
to be the safest and
appears to be the most successful. Laparoscopic cholecystectomy plus LBCDE appears
to reduce the risk of acute pancreatitis but may be associated with a higher risk
of biliary leak.
</p>
</div><p class="first" id="d3631509e444">This systematic review and meta-analysis
compares 4 surgical strategies that combine
laparoscopic cholecystectomy and a second technique to assess which strategy is most
successful in patients with gallstone disease with common bile duct stones.
</p>