Single-stage approach for the management of choledocolithiasis with concomitant cholelithiasis. Implementation of a protocol in a secondary hospital Robert Memba a,b,d,* , Sergio Gonz  alez a , Daniel Coronado a , Ver  onica Gonz  alez a , Fernando Mata a , Jos  e Antonio Rodrı´guez a , Carlos Mu¨ hlenberg a , Joan Sala a , Ruth Ribas a , Eva Pueyo a , Alfredo Mata c , Donal B. O'Connor b , Kevin C. Conlon b , Rosa Jorba d a Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Sant Joan Despı´-Moises Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain b Professorial Surgical Unit, Trinity College Dublin, Tallaght Hospital, Dublin, Ireland c Gastroenterologist Endoscopy Unit, Gastroenterology Department, Sant Joan Despı´-Moises Broggi Hospital, Consorci Sanitari Integral, Barcelona, Spain d Hepatobiliary and Pancreatic Surgery Unit, General Surgery Department, Joan XXIII University Hospital, Tarragona, Spain article info Article history: Received 11 July 2018 Received in revised form 14 November 2018 Accepted 18 December 2018 Available online xxx Keywords: Common bile duct stones Choledocholithiasis Single-stage treatment One-step treatment Transcystic approach Choledochotomy abstract Background: Current evidence shows that single-stage treatment of concomitant chol- edocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires consid- erable training. This study aimed to evaluate the implementation of a protocol for man- aging concomitant choledocholithiasis and cholelithiasis using single-stage treatment. Methods: A prospective cohort study of patients diagnosed with cholelithiasis and chol- edocholithiasis who were treated with the single-stage treatment e transcystic instru- mentation, choledocotomy or intraoperative endoscopic retrograde cholangiopan- creatography (ERCP) e between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate. Results: 164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after “flushing” in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), chol- edochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%. Conclusions: Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a trans- cystic approach, with presumable low morbidity and cost-efficiency. © 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. * Corresponding author. Dr Mallafr e Guasch 4, Tarragona, 43005, Spain. E-mail address: rmembai.hj23.ics@gencat.cat (R. Memba). the surgeon xxx (xxxx) xxx Please cite this article as: Memba R et al., Single-stage approach for the management of choledocolithiasis with concomitant choleli- thiasis. Implementation of a protocol in a secondary hospital, The Surgeon, https://doi.org/10.1016/j.surge.2018.12.001 https://doi.org/10.1016/j.surge.2018.12.001 1479-666X/© 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.