Ricci C, et al. - Researchers performed a comparison of the efficacy and safety of 4 surgical approaches to gallstone disease with biliary duct calculi. Outcomes suggested the combined laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography (IntraERCP) approach as the safest approach. This approach seemed to be the most successful. The risk of acute pancreatitis appeared reduced with laparoscopic cholecystectomy plus LBCDE. However, a higher risk of biliary leak was noted in association with this approach. Minimally Invasive Surgery, Surgery, Hepatobiliary Disease, Gastroenterology and Hepatology

Methods

• Data sources included MEDLINE, Scopus, and ISI-Web of Science databases, articles published between 1950 and 2017 and searched from August 12, 2017, to September 14, 2017.
• Terms used for search included LCBDE, LC, preoperative, ERCP, postoperative, period, cholangiopancreatography, endoscopic, retrograde, rendezvous, intraoperative, one-stage, two-stage, single-stage, gallstone, gallstones, calculi, stone, therapy, treatment, therapeutics, surgery, surgical, procedures, clinical trials as topic, random, and allocation in several logical combinations.
• They selected randomized clinical trials that compare 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).
• Researchers performed a frequentist random-effects network meta-analysis.
• To show the probability that each approach would be the best for each outcome, they used the surface under the cumulative ranking curve (SUCRA).
• Primary outcomes assessed included 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.
• Acute pancreatitis, biliary leak, overall bleeding, operative time, length of hospital stay, total cost, and readmission rate were the secondary outcomes assessed.

Results

• Researchers identified 20 trials comprising 2489 patients (and 2489 procedures).
• With respect to morbidity, laparoscopic cholecystectomy plus IntraERCP showed the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%).
• In terms of overall mortality, similar results were obtained with all approaches.
• 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 LCBDE was noted to be the most successful approach.
• Regarding length of hospital stay, laparoscopic cholecystectomy plus IntraERCP provided the best results (SUCRA, 92.7%).
• Findings suggested inconsistency in terms of operative time (indirect estimate, 19.05; 95% CI, 2.44-35.66; P=.02) and total cost (indirect estimate, 17.06; 95% CI, 3.56-107.21; P=.04).
• Observation revealed heterogeneity for success rate (τ , 0.8), operative time (τ , >1), length of stay (τ , >1), and total cost (τ , >1).