Published online Sep 18, 2026. doi: 10.13105/wjma.121913
Revised: May 17, 2026
Accepted: June 10, 2026
Published online: September 18, 2026
Processing time: 160 Days and 12.4 Hours
Cholecystocholedocholithiasis is conventionally managed by two-step endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cho
To compare the outcomes of patients with cholecystocholedocholithiasis under
Standard medical databases such as MEDLINE, EMBASE, PubMed, and Cochrane Library were searched to identify randomized controlled trials comparing out
A total of six randomized, controlled trials were included comprising 952 patients (LERV: n = 480; two-step ERCP + laparoscopic cholecystectomy: n = 472). Random effect model analysis revealed that overall morbidity was reduced in patients undergoing LERV [odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.26-0.73, Z = 3.19, P = 0.001]. There were fewer postoperative pancreatitis cases when LERV was used; however, this was not statistically sig
LERV was associated with a reduced length of hospital stay and morbidity compared with two-step ERCP and laparoscopic cholecystectomy.
Core Tip: Cholecystocholedocholithiasis is conventionally managed by two-step endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy. Laparoscopic-endoscopic rendezvous (LERV) offers a single-stage alternative. This meta-analysis of six randomized controlled trials (952 patients) demonstrates that LERV significantly reduces hospital stay and overall morbidity compared with the two-step strategy without compromising common bile duct stone clearance or increasing post-procedure pancreatitis. These findings support wider adoption of LERV in centers with appropriate expertise.
- Citation: Mahmood WU, Lubbad O, Hamed O, Shafique S, Khera G, Singh KK, Sajid MS. Single-step laparoscopic surgery reduces postoperative morbidity in the management of gallstones. World J Meta-Anal 2026; 14(3): 121913
- URL: https://www.wjgnet.com/2308-3840/full/v14/i3/121913.htm
- DOI: https://dx.doi.org/10.13105/wjma.121913
Stones in the common bile duct (CBD), termed choledocholithiasis, are known to affect 20% of patients with biliary colic symptoms[1]. These tend to pass through the major duodenal papilla naturally but can sometimes cause complications such as ascending cholangitis and acute pancreatitis. When these stones are simultaneously present in the gallbladder, this is known as cholecystocholedocholithiasis[2]. There are three principal strategies for the management of cholecystocholedocholithiasis: Traditional two-step endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy, a novel single-stage laparoscopic-endoscopic rendezvous (LERV), and other procedures such as laparoscopic CBD exploration combined with laparoscopic cholecystectomy[3].
The standard treatment for cholecystocholedocholithiasis is a two-step procedure, comprising ERCP to remove CBD stones followed by an elective laparoscopic cholecystectomy[3]. While this is an effective method for removing gallstones, it has limitations. ERCP risks include acute pancreatitis, hemorrhage, and duodenal perforation[4]. Furthermore, the period between ERCP and laparoscopic cholecystectomy risks recurrent CBD stones, prolonging treatment. An emerging treatment option is the LERV procedure, which is a single-step technique combining intraoperative ERCP with a simul
This was previously reported in a systematic review and meta-analysis by Lin et al[6], comparing the two-step app
This meta-analysis was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, ensuring a methodologically rigorous approach to study selection, data extraction and synthesis[7].
A search of electronic databases, including MEDLINE, EMBASE, PubMed and The Cochrane Library, was performed. RCTs published until June 2025 were identified using the medical subject headings “ERCP and laparoscopic cholecystectomy”, “laparoscopic-endoscopic rendezvous” and “cholecystocholedocholithiasis”. Boolean operators (AND, OR, NOT) were used to refine results. The titles were independently reviewed by two authors and were either selected or removed from the study. The reference list of included studies was also screened, and a supplementary grey literature search via Google was performed to ensure all records were screened. The accuracy of the included studies was confirmed by a third author who reviewed the selected studies.
Only studies of human participants directly comparing two-step ERCP followed by laparoscopic cholecystectomy vs one-step LERV in the management of cholecystocholedocholithiasis were chosen. Studies that only examined CBD stones or cholelithiasis were excluded. Quasi-experimental studies, cohort studies, case-control studies and non-RCTs were also excluded. There was no restriction on the country of origin, language or hospital. The primary outcomes searched for included length of stay, overall morbidity, rates of postoperative pancreatitis and successful CBD stone clearance rates. The process and outcome of the literature search are illustrated in Figure 1.
Within a predefined meta-analysis form, two independent reviewers extracted relevant data from the RCTs, and the accuracy was confirmed by a third reviewer. Any discrepancies in the selection of trials or data extraction were resolved by the third author.
All statistical analyses were performed using Review Manager (RevMan) version 5.4, developed by the Cochrane Collaboration. For dichotomous outcomes, odds ratios (OR) with a 95% confidence interval (CI) were used, whereas standardized mean difference (SMD) with 95%CI were used for continuous variables. The random-effects model was applied to account for any heterogeneity between studies[8,9]. Statistical heterogeneity was measured using the χ2d (χ2) test, with the significance threshold set at P < 0.05. The degree of heterogeneity was further quantified with the inclusion of the I2 statistic, with a value under 30% indicating low heterogeneity, 30%-60% indicating moderate heterogeneity and > 60% indicating high heterogeneity.
In cases where standard deviation was not reported, it was estimated using the Cochrane Handbook recommendations[10]. Equal variance was assumed between groups and either the range reported or the P-value was used to estimate standard deviation. For dichotomous events with zero events, a continuity correction of 0.5 was added, in accordance with Deeks et al[11]. The Mantel-Haenszel method under the random-effects model was used to pool any binary data[12].
Results were presented as forest plots. Each square represented the point estimate from an individual study, with its size proportional to the study’s weight, and the accompanying horizontal line marking the 95%CI.
The methodological quality of the included trials was assessed using the published guidelines of the Cochrane quality assessment tool[10]. Given the small number of included trials (n = 6), subgroup analysis, meta-regression and formal sensitivity analyses were not performed, as these methods require a minimum number of studies to yield reliable estimates.
The primary search of databases amounted to 161 studies. Screening of abstracts and titles decreased this to eight studies. Two studies were excluded because they did not examine cholecystocholedocholithiasis (i.e., they examined CBD stones or cholelithiasis in isolation without the combined presentation). Therefore, six RCTs were ultimately included (Figure 1).
Six RCTs on 952 patients were included in this updated comprehensive meta-analysis on one-step LERV vs two-step ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis, utilizing the principles advised by The Cochrane Collaboration. The trials included were based in Egypt[13], Italy[14,15], Spain[16], India[17] and Greece[18]. Table 1 outlines the primary demographic characteristics of the included studies, whilst Table 2 highlights the protocol used in each study.
| Ref. | Country | Number of recruited patients | Age in years | Female:Male | Duration of follow up | Trial running time |
| Farid et al[13], 2024 | Egypt | LERV: 218; No LERV: 218 | LERV: 39.56 ± 12.31; No LERV: 44.44 ± 10.18 | LERV: 93:125; No LERV: 156:62 | 1 year | January 2010 to April 2022 |
| Lella et al[14], 2006 | Italy | LERV: 60; No LERV: 60 | LERV: 54.2 ± 9.51 | LERV: 33:27; No LERV: 35:25 | 24 hours | January 2002 to September 2004 |
| Morino et al[15], 2006 | Italy | LERV: 46; No LERV: 45 | LERV: 56.6 ± 151; No LERV: 63.1 ± 14.51 | LERV: 31:15; No LERV: 25:20 | 20 months | May 2001 to August 2005 |
| Rábago et al[16], 2006 | Spain | LERV: 64; No LERV: 59 | Not reported | Not reported | 24 months | June 1999 to June 2003 |
| Sahoo et al[17], 2014 | India | LERV: 42; No LERV: 41 | LERV: 47.95 ± 13.51 | LERV: 53:30 | 30 days | 2005 to 2012 |
| Tzovaras et al[18], 2012 | Greece | LERV: 50; No LERV: 49 | LERV: 66 ± 16.251; No LERV: 69 ± 151 | LERV: 27:23; No LERV: 26:23 | Not reported | September 2006 to April 2009 |
| Ref. | LERV | No-LERV |
| Farid et al[13], 2024 | Treated by a single-step procedure combining laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy | Treated by a two-step (sequential treatment) preoperative endoscopic sphincterotomy followed by laparoscopic cholecystectomy; scheduling for laparoscopic cholecystectomy in the control group ranged from within 8 weeks after preoperative ERCP |
| Lella et al[14], 2006 | Patients in group A underwent a single-session procedure under general anesthesia, starting with intraoperative cholangiography to confirm duct stones; following this, a video duodenoscope was used for ERCP, facilitated by a surgeon-placed guidewire through the cystic duct for rapid papillary cannulation, sphincterotomy, and stone removal, after which cholecystectomy was completed | Treated with preoperative ERCP and EST using a traditional method of bile duct cannulation; all patients in the control group were scheduled for laparoscopic cholecystectomy within 24 hours to 48 hours after ERCP; No drugs for prophylactic prevention of post-ERCP pancreatitis were administered before the two procedures; treated by the same endoscopist with experience of 200 ERCPs a year |
| Morino et al[15], 2006 | The intervention group underwent laparoscopic cholecystectomy associated with intraoperative ERCP and ES according to the rendezvous technique | Patients underwent a pre-op ERCP with endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy in the same hospital admission |
| Rábago et al[16], 2006 | Intraoperative cholangiography during laparoscopic cholecystectomy, and if stones were found, an intraoperative ERCP was performed | Patients treated with the standard 2-step treatment, pre-op ERCP followed by laparoscopic cholecystectomy within the next 8 weeks, provided that no post-ERCP complication had occurred |
| Sahoo et al[17], 2014 | Patients were treated with LC and intra-operative cholangiography, and when the diagnosis of choledocholithiasis was confirmed, patients had undergone one-step management by the laparo-endoscopic rendezvous technique; included patients were diagnosed with cholelithiasis and choledocholithiasis | Treated with the first stage of pre-operative ERCP and CBD clearance by standard technique, and a second step of a classical four-port laparoscopic cholecystectomy |
| Tzovaras et al[18], 2012 | The intervention group was offered the 1-step LERV technique; only patients with a positive MRCP were included in the study | Patients treated with standard 2-step treatment; pre-op ERCP followed by laparoscopic cholecystectomy within the next 48 hours, provided that no post-ERCP complication had occurred |
Table 3 assesses the methodological quality of each included RCT. In every study, randomization was performed through 1:1 allocation, either through computer-generated random numbers[13-17] or block randomization[18]. Concealment was reported in five RCTs[13,15-18]. An intention-to-treat analysis was performed in three RCTs[15,16,18]. Inclusion and exclusion criteria were reported in all studies[14-18].
| Ref. | Randomization technique | Power calculations | Blinding | Intention-to-treat analysis | Concealment | Inclusion criteria | Exclusion criteria |
| Farid et al[13], 2024 | 1:1 allocation via computer-generated random numbers | Not reported | Not reported | No | Yes | Reported | Reported |
| Lella et al[14], 2006 | 1:1 allocation via computer-generated random numbers | Reported | Not reported | No | No | Reported | Reported |
| Morino et al[15], 2006 | 1:1 allocation via computer-generated random numbers | Reported | Not reported | Yes | Yes | Reported | Reported |
| Rábago et al[16], 2006 | Allocation via random number generation | Reported | Not reported | Yes | Yes | Reported | Reported |
| Sahoo et al[17], 2014 | 1:1 allocation via computer-generated random numbers | Not reported | Not reported | No | Yes | Reported | Reported |
| Tzovaras et al[18], 2012 | 1:1 allocation via block randomization | Reported | Not reported | Yes | Yes | Reported | Reported |
The individual outcome variables are described as follows:
Overall morbidity: Random effect model analysis demonstrated that morbidity was significantly lower within the LERV procedure group (OR = 0.43; 95%CI: 0.26-0.73, Z = 3.19, P = 0.001). There was low heterogeneity among included trials (Tau2 = 0.05; χ2 = 4.57, df = 4; P = 0.33; I2 = 13%), as displayed in Figure 2A.
Postoperative complications - acute pancreatitis: In the random effect model analysis, the rates of developing acute pancreatitis were not statistically different between the two procedures (OR = 0.37; 95%CI: 0.06-2.39, Z = 1.04, P = 0.30). However, there was high heterogeneity among included trials (Tau2 = 3.04; χ2 = 15.29, df = 4; P = 0.004; I2 = 74%)(Figure 2B).
Successful CBD stone clearance: In random effect model analysis, LERV did not demonstrate a statistically higher rate of CBD stone clearance over ERCP and laparoscopic cholecystectomy (OR = 1.67; 95%CI: 0.61-4.58, Z = 1.00, P = 0.32). However, there was moderate heterogeneity among included studies (Tau2 = 0.86; χ2 = 11.86, df = 5; P = 0.04; I2 = 58%)(Figure 2C).
Length of stay: In the random effect model analysis, LERV was associated with a statistically significant shorter length of stay (Standardized mean difference: -1.05; 95%CI: -1.65 to -0.44, Z = 3.40, P = 0.0007). There was also high heterogeneity among included studies (Tau2 = 0.44; χ2 = 58.86, df = 4; P < 0.00001; I2 = 93%), as shown in Figure 2D.
This meta-analysis included six RCTs on 952 patients, comparing single-stage LERV to the conventional two-step management of cholecystocholedocholithiasis involving ERCP followed by laparoscopic cholecystectomy. Pooled analysis demonstrated that LERV significantly reduced hospital stay and postoperative morbidity, all without com
The reduction in morbidity and hospital stay with LERV is likely explained by several procedural advantages. The single-step approach avoids repeated anesthetic exposure and readmission. Furthermore, the delay between ERCP and a cholecystectomy may give rise to recurrent ductal obstruction or infection. Direct antegrade cannulation performed laparoscopically can facilitate smoother biliary access and minimize papillary trauma, which may explain the lower complication rate. Conversely, the traditional two-step strategy predisposes patients to known complications like bile leakage, pancreatitis and stone recurrence. Despite no significant difference in post-ERCP pancreatitis rates, there is a clear trend towards reduced rates in LERV, supporting the theoretical benefits of wire-guided cannulation, which is known to be less traumatic to the papilla compared with blind retrograde cannulation. Despite this, the lack of statistical significance likely reflects the relatively small sample size of the included trials and low overall frequency of pancreatitis.
Our results are consistent with previous meta-analyses, which reported reduced morbidity and hospital stay with LERV[6]. However, the present study exclusively synthesizes data from RCTs, strengthening the reliability of these conclusions. Moreover, recent retrospective studies[2] support the growing evidence that the single-stage approach is an effective and safe alternative. Previous meta-analyses by Liao et al[19] and Chaouch et al[20] demonstrated that a combined approach was safer for patients, further reinforcing our findings. Our study uniquely analyzes only RCT, further validating the LERV approach and providing higher-level causal evidence. Collectively, these findings demonstrate that single-stage approaches, such as LERV and laparoscopic CBD exploration, may represent optimal strategies where institutional expertise allows, as local experience and resources should guide the approach.
Endoscopic ultrasound and magnetic resonance cholangiopancreatography provide high sensitivity and specificity for the preoperative characterization of CBD stones, including intrahepatic stones. This preoperative information can aid in identifying patients in whom intraoperative endoscopic clearance may be technically demanding. In such cases, LERV can offer its advantages through antegrade wire-guided cannulation, reducing papillary trauma. LERV also preserves the option of completing stone clearance with postoperative ERCP if full intraoperative clearance is not achieved, which makes it a flexible strategy in more complex cases.
To our knowledge, this meta-analysis restricted exclusively to RCTs, is the most up-to-date review on the comparison between LERV and ERCP and laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis. The methodological quality of the included studies was not excellent, due to moderate clinical and methodological diversity between studies. Randomization was reported in all studies[14-18] and concealment was reported in[13,15,17,18], which may be a source of heterogeneity. Blinding was not reported in any study despite all included studies being RCTs. Inclusion and exclusion criteria were reported in all six studies. With regards to the outcomes, such as complications, successful stone clearance and overall morbidity, we analyzed them generally without identifying specific causes. Therefore, there may be several confounding factors that impact the outcome of these postoperative variables. The limited trial data meant that subgroup analysis or funnel plot analysis could not be performed. Therefore, we cannot explicitly say LERV is a superior treatment option, but our analysis demonstrates that there is strong rationale for its clinical use.
There was significant heterogeneity in the analysis of hospital stay, likely due to institutional variation in discharge policies, differences in surgical experience and inclusion criteria. We can therefore conclude that the pooled analysis of length of stay is unreliable and should be interpreted with caution. This extreme heterogeneity may be due to several reasons, including variable definitions of discharge criteria and hospital stay measurement across different healthcare systems (Egypt, Italy, Spain, India, Greece), differences in baseline stone burden and patient complexity, differences in surgical experience and institutional volume or heterogeneity in ERCP scheduling in the control arm, ranging from within 24 hours to 48 hours to up to 8 weeks post-ERCP.
Some trials included patients with suspected rather than confirmed CBD stones, which may have affected diagnostic and perioperative processes. Within the postoperative pancreatitis outcome, continuity corrections were applied, where one arm had zero events in a trial, and this may have modestly attenuated the estimated OR, which is a limitation. While randomization was consistently reported, blinding and allocation concealment were not uniformly applied, which may have introduced bias. Due to the small number of trials available, a definitive assessment of publication bias was not conducted based on Cochrane guidelines[10]. We also applied a generalized definition of morbidity across trials, introducing a potential source of between-study variation. Future trials should adopt standardized outcome definitions such as the Clavien-Dindo classification.
This study reinforces the growing body of evidence suggesting that LERV is a safe and effective treatment option in the management of cholecystocholedocholithiasis and can be utilized over the traditional two-step approach. The reduction in overall morbidity and hospital stay may translate into improved perioperative experiences for patients. While there was no statistically significant difference in CBD stone clearance or acute pancreatitis between the two approaches, LERV provides more favorable outcomes overall. These findings support a more widespread adoption of LERV. Clinically, a single-stage procedure may streamline patient care by reducing waiting times, bed occupancy and costs associated with multiple admissions. From an educational standpoint, LERV demonstrates the growing integration of multidisciplinary techniques in modern surgery. Collaborating with endoscopists will improve safety and efficiency, thereby improving patient outcomes. This aligns with the broader trend towards minimally invasive, patient-centered surgical management.
Further data will be required to assess long-term outcomes, recurrence rates, and to study patient outcomes based on surgical risk groups. Given the relative scarcity of RCTs, further studies should focus on methodological rigor to help reduce heterogeneity among trials. Further work is also required to assess the cost-effectiveness of switching to a one-step procedure. The establishment of LERV training modules and standardized clinical pathways can help ensure safe implementation and reproducibility of results across institutions. Additionally, subgroup analyses on stone size, operative time or patient comorbidities were not possible with the included data, and future studies should focus on these variables.
This meta-analysis provides the most up-to-date and robust evidence that the single-stage LERV procedure is an effective alternative to the conventional two-step management involving ERCP followed by laparoscopic cholecystectomy for the management of cholecystocholedocholithiasis. LERV was associated with a statistically significant reduction in overall postoperative morbidity without compromising the ability to successfully remove CBD stones compared with the two-step procedure. As surgical and endoscopic techniques continue to evolve, further high-quality, multicenter trials are needed to confirm these findings and explore their application across different healthcare settings.
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