Single-Stage Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stones: A Feasibility Study

Single-Stage Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stones: A Feasibility Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Single-Stage Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stones: A Feasibility Study Manish Kak, Sushil Fotedar, Vinca Kaul Kak, Hitendra Sharma, Yogesh Agarwala, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6641137/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Combining laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) in a single session offers a promising, efficient approach for managing patients with concurrent gallstones and choledocholithiasis. Methods: This feasibility study included 1008 patients diagnosed with both cholelithiasis and choledocholithiasis who underwent a single-stage procedure. In 92% of cases, the procedure was successful. In patients with large or multiple (more than 10–12) CBD stones, clearance was achieved via laparoscopic choledocholithotomy. Minor intraoperative bleeding occurred in 20 patients and was managed conservatively. Results: The single-stage approach demonstrated high success and low complication rates. The mean hospital stay was 2 days. Patients with mild preoperative pancreatitis had a slightly longer postoperative stay. Conclusion: The single-stage procedure minimizes hospital stay, reduces costs, and eliminates the risks associated with the two-stage approach, such as post-ERCP pancreatitis and cannulation failure. Our findings support that, in carefully selected patients, combined LC and ERCP is a safe and effective strategy for managing concurrent gallstones and CBD stones. Common bile duct stone Single-stage procedure Laparoscopic cholecystectomy ERCP Choledocholithiasis Figures Figure 1 Introduction Obstructive jaundice, often caused by common bile duct (CBD) stones, is an early and significant indicator of hepatobiliary dysfunction. Most CBD stones originate in the gallbladder and migrate to the duct. Among patients undergoing cholecystectomy for symptomatic gallstones, choledocholithiasis is reported in approximately 3–15% of cases. [1–3] Traditionally, management of concurrent gallstones and CBD stones involves a two-stage approach: endoscopic CBD clearance followed by laparoscopic cholecystectomy (LC), or vice versa [4]. This method requires coordination between two teams—an endoscopist and a surgeon—and, while effective, often leads to extended hospital stays and increased treatment costs. [5, 6] A single-stage approach, combining LC with intraoperative ERCP (IO-ERCP), has emerged as a practical alternative [7]. This strategy minimizes procedural delays, ensures more reliable biliary access, avoids pre-cut papillotomy and associated risks (e.g., perforation, post-ERCP pancreatitis), and requires only a single anaesthesia session. Patients also benefit from faster recovery and reduced hospital stays, making the approach cost-effective. The objective of this study was to evaluate the feasibility, safety, and outcomes of the single-stage LC and ERCP technique in patients with concurrent cholelithiasis and choledocholithiasis. Materials and Methods This prospective feasibility study was conducted at Manipal Hospital (previously Columbia Asia Hospital), Ghaziabad, from January 2016 to December 2024. A total of 1008 patients diagnosed with concurrent cholelithiasis and choledocholithiasis were selected for a single-stage procedure involving laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP). Inclusion Criteria Confirmed diagnosis of gallstones with choledocholithiasis Patients with mild acute pancreatitis were also considered (n = 113) Exclusion Criteria CBD stones > 15 mm Significant comorbidities contraindicating prolonged anesthesia Contraindications to ERCP, including duodenal obstruction, altered anatomy, and coagulopathy All patients provided informed consent before the procedure. Ethics approval was obtained from the Institutional Ethics Committee of Manipal Hospital, Ghaziabad. Procedure Under general anesthesia, patients were intubated via the nasal route (Fig. 1 a). LC was initiated using the standard four-port technique (Fig. 1 b). After dissecting Calot’s triangle and mobilizing the gallbladder, the cystic duct was isolated, and a small incision was made. Through an additional abdominal puncture (Fig. 1 c), a guidewire was introduced via the cystic duct into the common bile duct (CBD) and advanced into the duodenum. Intraoperative ERCP was then performed by the gastroenterologist using a side-viewing Olympus EVIS EXERA III scope (CLV 190, TJF Q190V) under CO₂ insufflation, with the patient in the supine position. The guidewire was retrieved from the duodenal papilla using a snare through the scope’s biopsy channel (Fig. 1 d–e). A sphincterotome was threaded over the guidewire, cannulating the papilla (Fig. 1 f), followed by cholangiogram, sphincterotomy, and stone extraction using a Dormia basket or extraction balloon. CBD clearance was confirmed by balloon sweep and fluoroscopic imaging. In uncertain cases, a 7F–7 cm double pigtail stent was placed and removed 4 weeks post-procedure. If the guidewire could not traverse the papilla due to large or multiple (> 10–12) stones, the procedure was converted to laparoscopic choledocholithotomy. After manual stone removal and guidewire placement via CBD, the gastroenterologist inserted a biliary stent endoscopically as above. The CBD was closed primarily over the stent, avoiding T-tube placement. Postoperative Care Patients were monitored for vital signs and procedure-related complications. Serum amylase was measured in cases of postoperative abdominal pain to assess for pancreatitis. Oral intake was resumed on the day of surgery, and most patients were discharged within 1–3 days after regaining ambulation and tolerating oral feeds. Results A total of 1008 patients underwent the single-stage procedure for concurrent cholelithiasis and choledocholithiasis. The cohort consisted of 202 males and 806 females. The mean duration of symptoms was 15 weeks (range: 1 day to 5 years). Clinical Presentation and Laboratory Findings Clinical features at presentation are summarized in Table 1 . The most common symptoms were abdominal pain (100%), jaundice (84.8%), and fever (29.9%). A subset of patients (n = 113) presented with mild acute pancreatitis, while 25 had a history of prior pancreatitis. Laboratory evaluation revealed: Mean serum bilirubin: 4.3 mg/dL (range: 0.9–7.7) SGOT: 205 U/L (range: 35–602) SGPT: 202 U/L (range: 25–450) Alkaline phosphatase: 420 U/L (range: 95–1204) Serum amylase: 90 U/L (range: 20–380) Serum lipase: 70 U/L (range: 10–460) A total of 815 patients showed deranged liver function tests (elevated bilirubin and/or transaminases). Abdominal ultrasonography confirmed gallstones in all patients and revealed CBD stones with ductal dilation in 842 cases. Magnetic resonance cholangiopancreatography (MRCP) was performed in all patients to confirm choledocholithiasis. Procedural Outcomes Mean procedure time: 52 minutes (range: 35–90 minutes) Successful single-stage clearance: 927 patients (92%) Conversion to laparoscopic choledocholithotomy: 81 patients (8%) due to large or multiple CBD stones (> 10–12) Minor intraoperative bleeding occurred in 20 patients and was managed conservatively. There were no cases of perforation, post-ERCP pancreatitis, or anesthesia-related complications. Postoperative Recovery Mean hospital stay: 2 days (range: 1–3 days) in patients with successful single-stage procedures Patients with preoperative mild pancreatitis had a longer mean hospital stay (range: 4–6 days) Table 1 Clinical presentation of the study group (n = 1008) Pain 1008 Fever 302 Jaundice 855 Acute pancreatitis 113 History of pancreatitis 25 Discussion This feasibility study demonstrates that a single-stage approach combining laparoscopic cholecystectomy (LC) with endoscopic retrograde cholangiopancreatography (ERCP) is a safe, effective, and resource-efficient method for managing patients with coexisting gallbladder and common bile duct (CBD) stones. By applying strict inclusion and exclusion criteria, we minimized the rate of failed endoscopic interventions. A 92% success rate was achieved in performing complete endoscopic clearance during the initial session. In the remaining cases, conversion to laparoscopic choledocholithotomy allowed for successful stone removal without major complications. The absence of severe adverse events such as post-ERCP pancreatitis or perforation, combined with a low rate of minor bleeding, underscores the safety profile of this approach. Our findings are consistent with those reported in earlier studies. Deslandres et al. (1993) first described intraoperative endoscopic sphincterotomy during LC as a viable technique for CBD clearance [8]. Subsequently, a multicenter randomized trial by Cuschieri et al. found no significant differences in success rates, morbidity, or mortality between single- and two-stage strategies, but highlighted a shorter hospital stay and reduced costs in the single-stage group [5]. Hospital stay and total cost of treatment were, however, much less with the single-stage laparoscopy group and the authors advocated the latter as the procedure of choice [5, 6]. This has further been established in follow-up studies [9, 10]. These benefits were similarly demonstrated by Gurusamy et al., who confirmed the safety and efficacy of intraoperative CBD clearance with added advantages of faster recovery and lower costs. [11]. In our cohort, the average procedure time (52 minutes) and hospital stay (2 days) compared favorably with those reported in the literature. For example, Greca et al. reported a mean procedure time of 104 minutes and an average hospital stay of 3.9 days, with similar success and morbidity rates. [7]. A key strength of our study is the rigorous patient selection and standardized protocol, which contributed to the high success rate and absence of major complications. Furthermore, the collaborative approach between surgical and endoscopic teams facilitated seamless transitions between procedures and minimized delays. Limitations of our study include its single-center design and lack of a control group undergoing the two-stage procedure. Long-term outcomes, including stone recurrence and biliary stricture formation, were not assessed and require future investigation. Overall, our results support that, in carefully selected patients, a single-stage laparoscopic-endoscopic approach is not only feasible but offers substantial clinical and logistical advantages over the traditional two-stage strategy. Conclusion In conclusion, the single-stage approach combining laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography is a safe, feasible, and effective strategy for managing patients with concurrent gallstones and choledocholithiasis. This method minimizes hospital stay, reduces treatment costs, and avoids the risks associated with two-stage procedures, such as cannulation failure and post-ERCP pancreatitis. Careful patient selection and a coordinated multidisciplinary team are critical to the success of this approach. Our findings support the integration of this technique into clinical practice for appropriately selected patients. Declarations Author Contributions MK conceptualized the study and performed endoscopic procedures. SF, HS, YA, AJ, and SA performed surgical procedures. VKK, AS, and PA helped with anesthesia management and patient care. MK and SF prepared the manuscript. All authors reviewed and approved the final manuscript. Ethics Approval and Consent to Participate The study was conducted as per the institutional research committee's ethical standard and the Helsinki declaration of 1964. Approval was gained from Manipal Hospital (previously Columbia Asia Hospital), Ghaziabad, Institutional Ethics Committee. Written informed consent was procured from all the individual study participants, for their personal, clinical details, identifying images to be published in the study. Competing Interests The authors declare that they have no competing interests. Financing This research received no external funding. Data Availability The Study Data cannot be provided, since the study was approved by our institutional ethics committee with the condition that raw patient data would remain confidential and not be shared publicly. References Sarli L, Iusco DR, Roncoroni L (2003) Preoperative endoscopic sphincterotomy and laparoscopic cholecystectomy for the treatment of cholecysto choledocholithiasis: 10-year experience. World J Surg 27:180–186 Schirmer BD, Winster KI, Edlich RF (2005) Cholelithiasis and cholecystitis. J Long-Term Eff Med Implants 15:329–338 Riciardi R, Islam S, Cante JJ et al (2003) Effectiveness and long term results of laparoscopic common bile duct exploration. Surg Endosc 17:19–22 Clayton ESJ, Connor S, Alexakis N, Leandros E (2006) Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with gallbladder in situ. Br J Surg 93:1185–1191 Cuschieri A, Lezoche E, Morino M et al (1999) E.A.E.S multicenter prospective randomized trial comparing two-stage vs single stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13:952–957 Rogers SJ, Cello JP, Horn JK et al (2010) Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg 145:28–35 Greca GL, Barbagallo F, Sofia M, Latteri S, Russello D (2010) Simultaneous laparo endoscopic rendezvous for the treatment of Cholecysto choledocholithiasis. Surg Endosc 24:769–780 Deslandres E, Gagner M, Pomp A, Rheault M et al (1993) Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy. Gastro intest Endosc 39:54–58 NIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy (2002) NIH Consens State Sci Statements 19:1–26. Martin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 19:CD003327 Gurusamy K, Sahay KS, Burroughs AK, Davidson BR (2011) Systematic review and meta-analysis of intraoperative versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones. Br J Surg 98:908–916. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6641137","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484520921,"identity":"c8ed2937-251a-4047-bd05-e21c13b8376d","order_by":0,"name":"Manish Kak","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYJCCA4wNCQwS7A0MzCRq4TlAghYGsBaJBCK16LafPXjw5440ecmZbww/F1TYMPC3dyfg1WJ2Ji/hMO+ZHMPZ0jnG0jPOpDFInDm7Ab+WAzkGhxnbKhjnSecYSPO2HWYwkMgloOX8G4ODP9sq7OdJnjH+TZyWGzkGB3jbchJnS/CYEWnLjTcGh3nb0pJn9qSVWfOcSeMh7JfzOcYff7Yl2844fnjzbZ4KGzn+9l78WpAAhwGI5CFWOQiwPyBF9SgYBaNgFIwgAADfTkqNOvVgIwAAAABJRU5ErkJggg==","orcid":"","institution":"Manipal Hospital","correspondingAuthor":true,"prefix":"","firstName":"Manish","middleName":"","lastName":"Kak","suffix":""},{"id":484520924,"identity":"378c42b7-b1fe-4ddc-8238-b0b15c9aaadd","order_by":1,"name":"Sushil Fotedar","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sushil","middleName":"","lastName":"Fotedar","suffix":""},{"id":484520925,"identity":"0d9e409c-f49c-47b1-8842-1b0a173fec92","order_by":2,"name":"Vinca Kaul Kak","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vinca","middleName":"Kaul","lastName":"Kak","suffix":""},{"id":484520926,"identity":"96ed2cd5-d294-4c3e-bddb-9ce7ae45f470","order_by":3,"name":"Hitendra Sharma","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hitendra","middleName":"","lastName":"Sharma","suffix":""},{"id":484520927,"identity":"8b4b314f-d38a-43ed-ae98-03fdcc9d361b","order_by":4,"name":"Yogesh Agarwala","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yogesh","middleName":"","lastName":"Agarwala","suffix":""},{"id":484520928,"identity":"1ef1c5b8-1991-45fa-86e8-837ae28b65a1","order_by":5,"name":"Ajay Jain","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ajay","middleName":"","lastName":"Jain","suffix":""},{"id":484520929,"identity":"dcd59dfa-d643-491b-89df-c9401130fd63","order_by":6,"name":"Ajay Sharma","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ajay","middleName":"","lastName":"Sharma","suffix":""},{"id":484520930,"identity":"a8218b7c-378b-4d0f-8c74-8e9305730446","order_by":7,"name":"Pawan Agarwal","email":"","orcid":"","institution":"Manipal Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pawan","middleName":"","lastName":"Agarwal","suffix":""}],"badges":[],"createdAt":"2025-05-11 18:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6641137/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6641137/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86672364,"identity":"728513de-a28b-4b18-a7b7-895612862760","added_by":"auto","created_at":"2025-07-14 11:39:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":451485,"visible":true,"origin":"","legend":"\u003cp\u003e(a) Transnasal intubation; (b) Laparoscopic cholecystectomy - four port approach; (c) small additional puncture to facilitate passage of guide wire; (d) guide wire passed into the abdominal cavity and pointed in the direction of the CBD; (e) guide wire passed from above emerging through the papilla, (f) guide wire passed from above caught up in snare and pulled back from the scope; (g) papilla cannulated with sphincterotome.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6641137/v1/5b60a67e96e8d3c4699a5daa.png"},{"id":86675619,"identity":"9e97db81-87b6-4495-a134-41b56a76c667","added_by":"auto","created_at":"2025-07-14 12:03:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1035981,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6641137/v1/76f28350-1ffa-4896-ba68-d00198782687.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Single-Stage Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stones: A Feasibility Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObstructive jaundice, often caused by common bile duct (CBD) stones, is an early and significant indicator of hepatobiliary dysfunction. Most CBD stones originate in the gallbladder and migrate to the duct. Among patients undergoing cholecystectomy for symptomatic gallstones, choledocholithiasis is reported in approximately 3\u0026ndash;15% of cases. [1\u0026ndash;3]\u003c/p\u003e\u003cp\u003eTraditionally, management of concurrent gallstones and CBD stones involves a two-stage approach: endoscopic CBD clearance followed by laparoscopic cholecystectomy (LC), or vice versa [4]. This method requires coordination between two teams\u0026mdash;an endoscopist and a surgeon\u0026mdash;and, while effective, often leads to extended hospital stays and increased treatment costs. [5, 6]\u003c/p\u003e\u003cp\u003eA single-stage approach, combining LC with intraoperative ERCP (IO-ERCP), has emerged as a practical alternative [7]. This strategy minimizes procedural delays, ensures more reliable biliary access, avoids pre-cut papillotomy and associated risks (e.g., perforation, post-ERCP pancreatitis), and requires only a single anaesthesia session. Patients also benefit from faster recovery and reduced hospital stays, making the approach cost-effective.\u003c/p\u003e\u003cp\u003eThe objective of this study was to evaluate the feasibility, safety, and outcomes of the single-stage LC and ERCP technique in patients with concurrent cholelithiasis and choledocholithiasis.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis prospective feasibility study was conducted at Manipal Hospital (previously Columbia Asia Hospital), Ghaziabad, from January 2016 to December 2024. A total of 1008 patients diagnosed with concurrent cholelithiasis and choledocholithiasis were selected for a single-stage procedure involving laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eInclusion Criteria\u003c/h2\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eConfirmed diagnosis of gallstones with choledocholithiasis\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients with mild acute pancreatitis were also considered (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCBD stones\u0026thinsp;\u0026gt;\u0026thinsp;15 mm\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSignificant comorbidities contraindicating prolonged anesthesia\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eContraindications to ERCP, including duodenal obstruction, altered anatomy, and coagulopathy\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e All patients provided informed consent before the procedure. Ethics approval was obtained from the Institutional Ethics Committee of Manipal Hospital, Ghaziabad.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eUnder general anesthesia, patients were intubated via the nasal route (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). LC was initiated using the standard four-port technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eb). After dissecting Calot\u0026rsquo;s triangle and mobilizing the gallbladder, the cystic duct was isolated, and a small incision was made. Through an additional abdominal puncture (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ec), a guidewire was introduced via the cystic duct into the common bile duct (CBD) and advanced into the duodenum.\u003c/p\u003e\u003cp\u003eIntraoperative ERCP was then performed by the gastroenterologist using a side-viewing Olympus EVIS EXERA III scope (CLV 190, TJF Q190V) under CO₂ insufflation, with the patient in the supine position. The guidewire was retrieved from the duodenal papilla using a snare through the scope\u0026rsquo;s biopsy channel (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed\u0026ndash;e). A sphincterotome was threaded over the guidewire, cannulating the papilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef), followed by cholangiogram, sphincterotomy, and stone extraction using a Dormia basket or extraction balloon. CBD clearance was confirmed by balloon sweep and fluoroscopic imaging. In uncertain cases, a 7F\u0026ndash;7 cm double pigtail stent was placed and removed 4 weeks post-procedure.\u003c/p\u003e\u003cp\u003eIf the guidewire could not traverse the papilla due to large or multiple (\u0026gt;\u0026thinsp;10\u0026ndash;12) stones, the procedure was converted to laparoscopic choledocholithotomy. After manual stone removal and guidewire placement via CBD, the gastroenterologist inserted a biliary stent endoscopically as above. The CBD was closed primarily over the stent, avoiding T-tube placement.\u003c/p\u003e\n\u003ch3\u003ePostoperative Care\u003c/h3\u003e\n\u003cp\u003ePatients were monitored for vital signs and procedure-related complications. Serum amylase was measured in cases of postoperative abdominal pain to assess for pancreatitis. Oral intake was resumed on the day of surgery, and most patients were discharged within 1\u0026ndash;3 days after regaining ambulation and tolerating oral feeds.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1008 patients underwent the single-stage procedure for concurrent cholelithiasis and choledocholithiasis. The cohort consisted of 202 males and 806 females. The mean duration of symptoms was 15 weeks (range: 1 day to 5 years).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eClinical Presentation and Laboratory Findings\u003c/h2\u003e\u003cp\u003eClinical features at presentation are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The most common symptoms were abdominal pain (100%), jaundice (84.8%), and fever (29.9%). A subset of patients (n\u0026thinsp;=\u0026thinsp;113) presented with mild acute pancreatitis, while 25 had a history of prior pancreatitis.\u003c/p\u003e\u003cp\u003eLaboratory evaluation revealed:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMean serum bilirubin: 4.3 mg/dL (range: 0.9\u0026ndash;7.7)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSGOT: 205 U/L (range: 35\u0026ndash;602)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSGPT: 202 U/L (range: 25\u0026ndash;450)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAlkaline phosphatase: 420 U/L (range: 95\u0026ndash;1204)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSerum amylase: 90 U/L (range: 20\u0026ndash;380)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSerum lipase: 70 U/L (range: 10\u0026ndash;460)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eA total of 815 patients showed deranged liver function tests (elevated bilirubin and/or transaminases). Abdominal ultrasonography confirmed gallstones in all patients and revealed CBD stones with ductal dilation in 842 cases. Magnetic resonance cholangiopancreatography (MRCP) was performed in all patients to confirm choledocholithiasis.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedural Outcomes\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMean procedure time: 52 minutes (range: 35\u0026ndash;90 minutes)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSuccessful single-stage clearance: 927 patients (92%)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConversion to laparoscopic choledocholithotomy: 81 patients (8%) due to large or multiple CBD stones (\u0026gt;\u0026thinsp;10\u0026ndash;12)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eMinor intraoperative bleeding occurred in 20 patients and was managed conservatively. There were no cases of perforation, post-ERCP pancreatitis, or anesthesia-related complications.\u003c/p\u003e\n\u003ch3\u003ePostoperative Recovery\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eMean hospital stay: 2 days (range: 1\u0026ndash;3 days) in patients with successful single-stage procedures\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePatients with preoperative mild pancreatitis had a longer mean hospital stay (range: 4\u0026ndash;6 days)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical presentation of the study group (n\u0026thinsp;=\u0026thinsp;1008)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1008\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFever\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e302\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJaundice\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e855\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAcute pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of pancreatitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis feasibility study demonstrates that a single-stage approach combining laparoscopic cholecystectomy (LC) with endoscopic retrograde cholangiopancreatography (ERCP) is a safe, effective, and resource-efficient method for managing patients with coexisting gallbladder and common bile duct (CBD) stones.\u003c/p\u003e\u003cp\u003eBy applying strict inclusion and exclusion criteria, we minimized the rate of failed endoscopic interventions. A 92% success rate was achieved in performing complete endoscopic clearance during the initial session. In the remaining cases, conversion to laparoscopic choledocholithotomy allowed for successful stone removal without major complications. The absence of severe adverse events such as post-ERCP pancreatitis or perforation, combined with a low rate of minor bleeding, underscores the safety profile of this approach.\u003c/p\u003e\u003cp\u003eOur findings are consistent with those reported in earlier studies. Deslandres et al. (1993) first described intraoperative endoscopic sphincterotomy during LC as a viable technique for CBD clearance [8]. Subsequently, a multicenter randomized trial by Cuschieri et al. found no significant differences in success rates, morbidity, or mortality between single- and two-stage strategies, but highlighted a shorter hospital stay and reduced costs in the single-stage group [5]. Hospital stay and total cost of treatment were, however, much less with the single-stage laparoscopy group and the authors advocated the latter as the procedure of choice [5, 6]. This has further been established in follow-up studies [9, 10]. These benefits were similarly demonstrated by Gurusamy et al., who confirmed the safety and efficacy of intraoperative CBD clearance with added advantages of faster recovery and lower costs. [11].\u003c/p\u003e\u003cp\u003eIn our cohort, the average procedure time (52 minutes) and hospital stay (2 days) compared favorably with those reported in the literature. For example, Greca et al. reported a mean procedure time of 104 minutes and an average hospital stay of 3.9 days, with similar success and morbidity rates. [7].\u003c/p\u003e\u003cp\u003eA key strength of our study is the rigorous patient selection and standardized protocol, which contributed to the high success rate and absence of major complications. Furthermore, the collaborative approach between surgical and endoscopic teams facilitated seamless transitions between procedures and minimized delays.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e of our study include its single-center design and lack of a control group undergoing the two-stage procedure. Long-term outcomes, including stone recurrence and biliary stricture formation, were not assessed and require future investigation.\u003c/p\u003e\u003cp\u003eOverall, our results support that, in carefully selected patients, a single-stage laparoscopic-endoscopic approach is not only feasible but offers substantial clinical and logistical advantages over the traditional two-stage strategy.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the single-stage approach combining laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography is a safe, feasible, and effective strategy for managing patients with concurrent gallstones and choledocholithiasis. This method minimizes hospital stay, reduces treatment costs, and avoids the risks associated with two-stage procedures, such as cannulation failure and post-ERCP pancreatitis.\u003c/p\u003e\u003cp\u003eCareful patient selection and a coordinated multidisciplinary team are critical to the success of this approach. Our findings support the integration of this technique into clinical practice for appropriately selected patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMK conceptualized the study and performed endoscopic procedures. SF, HS, YA, AJ, and SA performed surgical procedures. VKK, AS, and PA helped with anesthesia management and patient care. MK and SF prepared the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted as per the institutional research committee\u0026apos;s ethical standard and the Helsinki declaration of 1964. Approval was gained from Manipal Hospital (previously Columbia Asia Hospital), Ghaziabad, Institutional Ethics Committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was procured from all the individual study participants, for their personal, \u0026nbsp;clinical details, identifying images to be published in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinancing\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Study Data cannot be provided, since the study was approved by our institutional ethics committee with the condition that raw patient data would remain confidential and not be shared publicly.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSarli L, Iusco DR, Roncoroni L (2003) Preoperative endoscopic sphincterotomy and laparoscopic cholecystectomy for the treatment of cholecysto choledocholithiasis: 10-year experience. World J Surg 27:180\u0026ndash;186\u003c/li\u003e\n\u003cli\u003eSchirmer BD, Winster KI, Edlich RF (2005) Cholelithiasis and cholecystitis. J Long-Term Eff Med Implants 15:329\u0026ndash;338\u003c/li\u003e\n\u003cli\u003eRiciardi R, Islam S, Cante JJ et al (2003) Effectiveness and long term results of laparoscopic common bile duct exploration. Surg Endosc 17:19\u0026ndash;22\u003c/li\u003e\n\u003cli\u003eClayton ESJ, Connor S, Alexakis N, Leandros E (2006) Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with gallbladder in situ. Br J Surg 93:1185\u0026ndash;1191\u003c/li\u003e\n\u003cli\u003eCuschieri A, Lezoche E, Morino M et al (1999) E.A.E.S multicenter prospective randomized trial comparing two-stage vs single stage management of patients with gallstone disease and ductal calculi. Surg Endosc 13:952\u0026ndash;957\u003c/li\u003e\n\u003cli\u003eRogers SJ, Cello JP, Horn JK et al (2010) Prospective randomized trial of LC + LCBDE vs ERCP/S + LC for common bile duct stone disease. Arch Surg 145:28\u0026ndash;35\u003c/li\u003e\n\u003cli\u003eGreca GL, Barbagallo F, Sofia M, Latteri S, Russello D (2010) Simultaneous laparo endoscopic rendezvous for the treatment of Cholecysto choledocholithiasis. Surg Endosc 24:769\u0026ndash;780\u003c/li\u003e\n\u003cli\u003eDeslandres E, Gagner M, Pomp A, Rheault M et al (1993) Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy. Gastro intest Endosc 39:54\u0026ndash;58\u003c/li\u003e\n\u003cli\u003eNIH state-of-the-science statement on endoscopic retrograde cholangiopancreatography (ERCP) for diagnosis and therapy (2002) NIH Consens State Sci Statements 19:1\u0026ndash;26.\u003c/li\u003e\n\u003cli\u003eMartin DJ, Vernon DR, Toouli J (2006) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 19:CD003327\u003c/li\u003e\n\u003cli\u003eGurusamy K, Sahay KS, Burroughs AK, Davidson BR (2011) Systematic review and meta-analysis of intraoperative versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones. Br J Surg 98:908\u0026ndash;916.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Common bile duct stone, Single-stage procedure, Laparoscopic cholecystectomy, ERCP, Choledocholithiasis","lastPublishedDoi":"10.21203/rs.3.rs-6641137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6641137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003cbr\u003e\nCombining laparoscopic cholecystectomy (LC) and endoscopic retrograde cholangiopancreatography (ERCP) in a single session offers a promising, efficient approach for managing patients with concurrent gallstones and choledocholithiasis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cbr\u003e\nThis feasibility study included 1008 patients diagnosed with both cholelithiasis and choledocholithiasis who underwent a single-stage procedure. In 92% of cases, the procedure was successful. In patients with large or multiple (more than 10–12) CBD stones, clearance was achieved via laparoscopic choledocholithotomy. Minor intraoperative bleeding occurred in 20 patients and was managed conservatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nThe single-stage approach demonstrated high success and low complication rates. The mean hospital stay was 2 days. Patients with mild preoperative pancreatitis had a slightly longer postoperative stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nThe single-stage procedure minimizes hospital stay, reduces costs, and eliminates the risks associated with the two-stage approach, such as post-ERCP pancreatitis and cannulation failure. Our findings support that, in carefully selected patients, combined LC and ERCP is a safe and effective strategy for managing concurrent gallstones and CBD stones.\u003c/p\u003e","manuscriptTitle":"Single-Stage Laparoscopic Cholecystectomy and Endoscopic Removal of Common Bile Duct Stones: A Feasibility Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:39:48","doi":"10.21203/rs.3.rs-6641137/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5f48c5ab-5607-4dbb-89bd-b23fa458765c","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-14T11:39:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-14 11:39:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6641137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6641137","identity":"rs-6641137","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}