Transcystic or Transductal Stone Extraction during Single-Stage Treatment of Choledochocystolithiasis: A Systematic Review Jan Siert K. Reinders • Dirk J. Gouma • Dirk T. Ubbink • Bert van Ramshorst • Djamila Boerma Ó Socie ´te ´ Internationale de Chirurgie 2014 Abstract Background Choledochocystolithiasis can be managed by endoscopic retrograde cholangiopancreaticography (ERCP) or laparoscopically by transcystic (TC) or trans- ductal (TD) stone extraction. Objective The aim of this study was to systematically review safety and effectiveness of combined endoscopic/ laparoscopic management versus total laparoscopic man- agement for choledochocystolithiasis with specific emphasis on TC versus TD stone extraction. Methods MEDLINE/PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched systematically to identify trials on combined endoscopic/laparoscopic and total laparoscopic management for choledochocystolithia- sis. Laparoscopic common bile duct (CBD) exploration was divided into TD and TC approach. Primary outcomes were successful stone clearance from CBD, postoperative/ procedural morbidity, and mortality. Results Eight randomized trials with 965 patients were included. Successful bile duct clearance varied between 52.6 and 97 % in the ERCP groups, 80.4 and 100 % in the TC groups, and 58.3 and 100 % in the TD groups. There were more bile leaks after TD stone extraction (11 %) than after ERCP (1 %) and TC stone extraction (1.7 %). Total morbidity varied between 9.1 and 38.3 % in the ERCP groups, 7 and 10.5 % in the TC groups, and 18.4 and 26.7 % in the TD groups. Methodological and statistical heterogeneity among the trials precluded a meaningful meta-analysis. Conclusion Stone clearance rates are comparable between the three modalities, but TD stone extraction is associated with a higher risk of bile leaks and should only be performed by highly experienced surgeons. TC stone extraction seems a more accessible technique with lower complication rates. If unsuccessful, per- or postoperative endoscopic stone extraction is a viable option. Introduction Of patients with symptomatic gallbladder stones 3–10 % have concomitant common bile duct (CBD) stones [1–4]. Before the laparoscopic era, standard treatment consisted of open cholecystectomy and CBD exploration (OCBDE), with satisfactory results [5–8]. Since the availability of endoscopic retrograde cholangiopancreaticography (ERCP) in the 1970s, endoscopic treatment of CBD stones prior to cholecystectomy became a generally accepted alternative to open bile duct exploration [9, 10]. In the past two decades, laparoscopic cholecystectomy (LC) has become the gold standard and is nowadays the most commonly performed laparoscopic abdominal procedure. However, experience with laparoscopic CBD exploration (LCBDE) was limited due to the high success rates of endoscopic stone extraction and the relatively low number of patients. In most countries in Europe, patients suspected of having CBD stones gen- erally undergo preoperative ERCP and sphincterotomy followed by LC. Due to the rapidly expanding skills in J. S. K. Reinders (&) Á B. van Ramshorst Á D. Boerma Department of Surgery, St. Antonius Hospital, PO Box 2500, 3430 EM Nieuwegein, The Netherlands e-mail: jansiertkay@gmail.com D. J. Gouma Department of Surgery, Academic Medical Center, PO Box 22600, 1100 DD Amsterdam, The Netherlands D. T. Ubbink Department of Quality Assurance & Process Innovation, Academic Medical Center, PO Box 22600, 1100 DD Amsterdam, The Netherlands 123 World J Surg DOI 10.1007/s00268-014-2537-8