Transcystic Laparoscopic Common Bile Duct Exploration (LCBDE) Combined with Laparoscopic Cholecystectomy for Acute Biliary Presentations: A Comparative Cohort Study of Choledochoscope-Assisted and Dormia Basket-Only Techniques

Transcystic Laparoscopic Common Bile Duct Exploration (LCBDE) Combined with Laparoscopic Cholecystectomy for Acute Biliary Presentations: A Comparative Cohort Study of Choledochoscope-Assisted and Dormia Basket-Only Techniques | 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 Transcystic Laparoscopic Common Bile Duct Exploration (LCBDE) Combined with Laparoscopic Cholecystectomy for Acute Biliary Presentations: A Comparative Cohort Study of Choledochoscope-Assisted and Dormia Basket-Only Techniques Mohammed Qaid Al Obahi, Ayah A. Eyalawwad, Fajer Al-Ishaq, Ahmad Zarour, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9468228/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 Choledocholithiasis complicating acute cholecystitis is commonly managed by staged endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Single-stage transcystic laparoscopic common bile duct exploration (LCBDE) performed concurrently with LC offers a compelling alternative. Two transcystic techniques are in routine use: choledochoscope-assisted extraction and Dormia basket-only (fluoroscopy-guided) extraction. Direct comparative data on these approaches in an acute-care emergency setting are lacking. This study aimed to compare their outcomes in patients undergoing emergency LC for acute biliary presentations. Methods Retrospective cohort study at Hamad General Hospital, Doha, Qatar (January 2020–December 2021). After formal dataset verification (exclusion of one LC + IOC-only case and two duplicate entries), 154 patients undergoing attempted transcystic LCBDE were included: 41 (26.6%) in the choledochoscope group and 113 (73.4%) in the Dormia basket group. Patients were assigned to groups based on the primary instrument attempted (primary-attempt strategy). Primary outcome was intraoperative common bile duct (CBD) clearance rate. Secondary outcomes included cannulation success, postoperative ERCP requirement, complications, 30-day readmission, and length of stay. Between-group comparisons used Fisher’s exact test. Analyses were performed on both intention-to-treat (ITT) and per-protocol (PP) frameworks. The study adheres to STROBE guidelines. Results Both techniques achieved comparable outcomes across all measured endpoints. Using a primary-attempt strategy, cannulation success was 90.2% (37/41) in the choledochoscope group versus 90.3% (102/113) in the Dormia group ( p = 1.000). Per-protocol CBD clearance was 81.1% (30/37) versus 82.4% (84/102) respectively ( p = 1.000). Postoperative ERCP was required in 19.5% (8/41) versus 20.4% (23/113) of cases ( p = 1.000). Documented complication rate based on operative log entries was 1.3% (2/154; bile leak in one patient per group). No biliary injuries, duodenal injuries, or bleeding events were documented. Conclusions In this verified cohort of 154 patients undergoing emergency transcystic LCBDE, choledochoscope-assisted and Dormia basket-only approaches showed no statistically significant difference in rates of cannulation, intraoperative CBD clearance, postoperative ERCP requirement, or complications. Single-stage LCBDE is safe and effective in acute-care settings regardless of technique. Technique selection should be guided by intraoperative anatomy, stone burden, and available equipment rather than perceived superiority of either approach. Prospective randomised studies in matched acute-care cohorts are required to refine technique-selection criteria. Laparoscopic common bile duct exploration transcystic LCBDE choledochoscope Dormia basket acute cholecystitis choledocholithiasis single-stage biliary surgery ERCP acute-care surgery Figures Figure 1 Figure 2 Article Summary What is already known on this topic • Single-stage transcystic LCBDE combined with LC reduces staged ERCP-based management and is safe in elective and mixed cohorts. • Choledochoscope-assisted extraction enables direct stone visualisation; Dormia basket-only extraction requires a simpler instrument profile. • No large comparative study has examined these two techniques specifically in a purely acute-care emergency surgical setting. What this study adds • In a verified cohort of 154 emergency LCBDE cases, choledochoscope-assisted and Dormia basket-only techniques showed no statistically significant difference on any measured outcome: ~90% cannulation success using a primary-attempt strategy, ~82% per-protocol CBD clearance, ~20% postoperative ERCP, and ~1.3% documented bile leak rate. Diagnoses were grouped into acute cholecystitis and biliary colic categories based on operative and clinical documentation. • No statistically significant difference was found on any measured outcome (all p ≥ 0.463). • Both techniques are safe and viable in acute-care pathways; choice should be individualised to anatomy and available equipment. Background Biliary tract disease, including cholelithiasis and concomitant choledocholithiasis, is among the most common causes of emergency surgical admission worldwide, contributing substantially to morbidity and healthcare expenditure [ 1 ]. The conventional two-stage management pathway — endoscopic retrograde cholangiopancreatography (ERCP) for ductal clearance followed by interval laparoscopic cholecystectomy (LC) — is effective but carries the cumulative risks of procedure-specific complications (post-ERCP pancreatitis, bleeding, perforation), repeated general anaesthesia, prolonged hospitalisation, and the logistical burden of a staged admission [ 2 , 3 ]. Single-stage management — laparoscopic common bile duct exploration (LCBDE) performed concurrently with LC — has attracted increasing interest as a means of achieving definitive biliary clearance in a single operative episode. Multicentre series, randomised trials, and systematic reviews have consistently demonstrated high clearance rates and favourable perioperative safety profiles for transcystic LCBDE [ 4 – 7 ], with feasibility confirmed even in paediatric cohorts and after prior failed ERCP [ 8 , 9 , 17 ]. Adoption nonetheless remains limited in many centres, driven by the perceived need for specialised endoscopic equipment, a learning curve, and limited exposure during surgical training [ 10 ]. Two principal transcystic techniques are in current use. Choledochoscope-assisted LCBDE employs a flexible miniature endoscope introduced through the cystic ductotomy, enabling direct intraductal visualisation and targeted stone retrieval. Dormia basket-only LCBDE relies on fluoroscopic guidance to deploy a four-wire stone retrieval basket without endoscopic visualisation. Each technique carries theoretical advantages: the choledochoscope offers precision and visual confirmation of clearance; the Dormia basket is simpler, faster to set up, and available in virtually all laparoscopic suites. In practice, both are in routine use and technique selection is often opportunistic, governed by instrument availability and surgeon familiarity rather than evidence-based criteria. Existing comparative data on these two approaches are sparse, and no study has specifically evaluated them in a purely acute-care setting — where inflammatory tissue planes, pericholecystic oedema, and friable cystic ducts may differentially affect the performance of each instrument. The present study aimed to compare outcomes of choledochoscope-assisted and Dormia basket-only transcystic LCBDE in patients undergoing emergency LC for acute cholecystitis or severe biliary colic, using both ITT and PP analytical frameworks. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Methods Study Design and Setting This retrospective observational cohort study was conducted at Hamad Medical Corporation (HMC), a tertiary referral centre with a dedicated Acute Care Surgery Unit serving as the primary emergency surgical facility for four satellite hospitals in Doha, Qatar. The study period spanned January 1, 2020 to December 31, 2021. The study protocol was approved by the HMC Medical Research Center (Approval No. MRC-01-25-700). All procedures were performed in accordance with the Declaration of Helsinki [ 11 ]. Patient consent for anonymised data use was obtained or waived according to institutional policy. Dataset Verification Data were extracted from a prospectively maintained operative log supplemented by the institutional electronic medical record. Prior to any statistical analysis, the complete dataset underwent formal row-level verification. Three entries were excluded: one patient who underwent laparoscopic cholecystectomy with intraoperative cholangiography only (LC + IOC) without CBDE and therefore did not meet the inclusion criterion of attempted LCBDE; and two duplicate entries identified by identical hospital numbers. For each duplicate pair, the entry with the more complete outcome data was retained. The verified final cohort comprised 154 patients. Participants Inclusion Criteria Admission to the Acute Care Surgery Unit with a diagnosis of acute cholecystitis confirmed according to Tokyo Guidelines 2018 [ 12 ] (clinical, laboratory, and imaging criteria) or severe biliary colic; presence of CBD stones confirmed by preoperative imaging (abdominal ultrasound, MRCP, or EUS) or intraoperative cholangiography; performance of attempted transcystic LCBDE during the same LC; and cholecystectomy completed within the index admission within 7 days of symptom onset. Exclusion Criteria Previous biliary surgery (prior cholecystectomy or biliary reconstruction); severe comorbidity precluding laparoscopy (ASA class IV–V); incomplete operative data; management by an ERCP-first approach; and cases in which LC + IOC was performed without any attempted LCBDE. Technique Group Assignment Patients were assigned to technique groups based on the primary instrument attempted at the time of LCBDE. Cases in which the choledochoscope was the first instrument attempted — whether successful or not, and including cases where a Dormia basket was subsequently used after choledochoscope failure — were assigned to the Choledochoscope group. Cases in which only a Dormia basket was attempted were assigned to the Dormia group. This primary-attempt rule was applied consistently across all 154 cases, including those with entries of 'YES/FAILED' in the choledochoscope column. Variable Definitions Cannulation success successful entry of the cystic duct by any instrument attempted within the operative strategy, enabling performance of cholangiography and stone extraction. Cases where the choledochoscope failed but the Dormia basket subsequently achieved access were classified as cannulation success within the Choledochoscope group (primary-attempt strategy). This definition reflects procedural success of the treatment approach rather than isolated instrument performance. Intraoperative CBD clearance confirmed absence of filling defects on completion cholangiogram. Cases where saline flushing was used as an adjunct and subsequently achieved radiological clearance were classified as cleared; the flush represents an intraoperative manoeuvre and its success constitutes procedural clearance. Stones retained at completion of the operative procedure — regardless of subsequent ERCP outcome — were classified as retained (intraoperative outcome only). Postoperative ERCP any endoscopic retrograde cholangiopancreatography performed after the index operation, regardless of indication (retained stones, bile leak) or result (stone confirmed or not). Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) used for imaging only, without therapeutic endoscopic intervention, were not classified as postoperative ERCP. Complications explicitly documented events in the operative log or clinical record, including bile leak, pancreatitis, biliary injury, duodenal injury, and bleeding. Surgical Technique Laparoscopic Cholecystectomy Performed using a standard four-port technique. The critical view of safety was obtained before division of the cystic duct and artery in all cases. Intraoperative Cholangiography (IOC) IOC was routinely performed via cystic duct cannulation using a cholangiography catheter to confirm the presence, number, and size of CBD stones and to delineate biliary ductal anatomy prior to LCBDE. Choledochoscope-Assisted LCBDE A 3 mm flexible choledochoscope was introduced through a cystic ductotomy under direct vision. Stones were identified endoscopically and retrieved using a Dormia basket passed through the working channel under endoscopic guidance. Ductal clearance was confirmed visually where possible and by repeat fluoroscopic cholangiography. Dormia Basket-Only LCBDE A four-wire Dormia basket was introduced through the cystic duct under fluoroscopic guidance without direct endoscopic visualisation. Stones were captured and extracted through multiple passes as required. Clearance was confirmed by cholangiography. Saline Flushing Pressurised saline flushing through the cystic duct was performed in cases of suspected residual sludge or debris, particularly following unsuccessful cannulation attempts or after basket passes. Clearance was confirmed fluoroscopically. Technique Selection Technique selection was an intraoperative decision made by the operating surgeon, based on cystic duct diameter and anatomy, stone burden, instrument availability, and individual experience. The study was conducted with the participation of eight consultant surgeons and supervised surgical trainees, representing variable levels of LCBDE experience in a real-world acute-care environment. Postoperative Follow-up Patients were followed up clinically and with imaging as indicated for a minimum of three months postoperatively. ERCP was performed if clinical findings, biochemistry, or imaging suggested retained CBD stones or biliary complication. EUS or MRCP were used for diagnostic evaluation in selected cases. Statistical Analysis Categorical variables are presented as frequencies and percentages; continuous variables as mean ± standard deviation (SD) or median (interquartile range, IQR). Between-group comparisons used Fisher's exact test for categorical data and the independent-samples t -test or Mann–Whitney U test for continuous variables, as appropriate. A p value < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS v25 (IBM Corp., Armonk, NY, USA). Analyses were performed according to both ITT (all attempted cases) and PP (successfully cannulated cases only) frameworks. The study was conducted and reported in accordance with the STROBE guidelines for observational studies. Artificial intelligence language model assistance (Claude, Anthropic) was used in manuscript drafting and editing; all data analysis, clinical interpretation, and final content decisions were made by the authors. Results Participant Flow and Baseline Data The final study cohort comprised 154 patients who underwent attempted transcystic LCBDE during emergency laparoscopic cholecystectomy between January 2020 and December 2021. Three cases were excluded during dataset verification (one LC + IOC-only case without LCBDE attempt; two duplicate hospital-number entries), yielding the 154-patient cohort reported here. The mean patient age was 38.8 years (SD = 12.3), with a female predominance (64.6%, n = 100). The majority were classified ASA 2 (35.1%, n = 54) or ASA 2E (28.6%, n = 44). The predominant surgical indications were acute cholecystitis (53.2%, n = 82) and severe biliary colic (46.8%, n = 72). Diagnoses were grouped into these two categories based on operative documentation and clinical record review. Choledochoscope-assisted LCBDE was the primary attempted technique in 41 patients (26.6%) , and Dormia basket-only LCBDE in 113 patients (73.4%) . Figure 1 illustrates the patient flow from attempted LCBDE through cannulation, ductal clearance, and postoperative interventions. Operative Outcomes Using a primary-attempt strategy, cannulation success was 90.2% in the choledochoscope group (37/41) and 90.3% in the Dormia group (102/113) ( p = 1.000). Cannulation failed in 4 (9.8%) and 11 (9.7%) patients, respectively. Among the choledochoscope failures, a Dormia basket was subsequently attempted in 4 cases and achieved successful access in 3; for analytical purposes, these 4 cases remain within the choledochoscope group per the primary-attempt rule. Among successfully cannulated patients (per-protocol analysis), intraoperative CBD clearance was achieved in 30 of 37 (81.1%) in the choledochoscope group and 84 of 102 (82.4%) in the Dormia group ( p = 1.000). Residual filling defects were identified at completion cholangiography in 7 (18.9%) and 18 (17.6%) patients, respectively. In the ITT analysis, clearance was 75.6% (31/41) versus 77.9% (88/113) ( p = 0.829). Saline flushing was employed as an adjunct in cases of failed cannulation — 1 of 4 choledochoscope failures (25.0%) and 4 of 11 Dormia failures (36.4%) — resulting in successful completion cholangiography without formal ductal entry in those cases. ITT clearance figures include these saline-flush successes, consistent with the predefined intraoperative clearance definition (any confirmed absence of filling defects on completion cholangiogram, irrespective of the method used to achieve it). Overall, 31 of 154 patients (20.1%) required postoperative ERCP. In the choledochoscope group, 8 patients (19.5%) underwent postoperative ERCP; in the Dormia group, 23 (20.4%) required ERCP ( p = 1.000). Among patients in whom cannulation failed, ERCP was required in 2 of 4 (50.0%) in the choledochoscope group and 5 of 11 (45.5%) in the Dormia group ( p = 1.000). In most cases, ERCP was performed for suspected retained CBD stones and was therapeutic; a small number had negative findings on ERCP or subsequent EUS, confirming that intraoperative cholangiography carries a modest false-positive rate for stone detection in this setting. Table 1 Operative and Postoperative Outcomes by Technique Group (n = 154) Outcome Choledochoscope (n = 41) Dormia Basket (n = 113) p-value† Cannulation success 37/41 (90.2%) 102/113 (90.3%) 1.000 Cannulation failure 4/41 (9.8%) 11/113 (9.7%) 1.000 CBD clearance — ITT 31/41 (75.6%) 88/113 (77.9%) 0.829 CBD clearance — PP* 30/37 (81.1%) 84/102 (82.4%) 1.000 Retained stone — ITT 10/41 (24.4%) 25/113 (22.1%) 0.829 Postoperative ERCP 8/41 (19.5%) 23/113 (20.4%) 1.000 ERCP after cannulation failure 2/4 (50.0%) 5/11 (45.5%) 1.000 Saline flushing among failures 1/4 (25.0%) 4/11 (36.4%) 1.000 Bile leak 1/41 (2.4%) 1/113 (0.9%) 0.463 Pancreatitis 0/41 (0.0%) 0/113 (0.0%) — Biliary injury 0/41 (0.0%) 0/113 (0.0%) — Duodenal injury 0/41 (0.0%) 0/113 (0.0%) — Bleeding 0/41 (0.0%) 0/113 (0.0%) — *PP = per-protocol analysis (successfully cannulated cases only: choledochoscope n = 37, Dormia n = 102). †All p-values from Fisher's exact test, two-tailed. ITT = intention-to-treat. ERCP = endoscopic retrograde cholangiopancreatography. CBD = common bile duct. ITT and Per-Protocol Analyses In the ITT analysis, overall CBD clearance was 75.6% for the choledochoscope group and 77.9% for the Dormia group ( p = 0.829). Postoperative ERCP was required in 19.5% versus 20.4% ( p = 1.000). In the PP analysis restricted to successfully cannulated cases, CBD clearance was 81.1% and 82.4% respectively ( p = 1.000). Postoperative ERCP among PP cases was 13.5% (5/37) versus 18.6% (19/102) ( p = 0.611). Results are presented in Table 2 . No significant differences were identified between groups in either analytical framework. Table 2 Intention-to-Treat and Per-Protocol Analysis (n = 154) Outcome Choledochoscope Dormia Basket p-value† ITT analysis (all attempted: C n = 41, D n = 113) CBD clearance 31/41 (75.6%) 88/113 (77.9%) 0.829 Postoperative ERCP 8/41 (19.5%) 23/113 (20.4%) 1.000 PP analysis (cannulated cases: C n = 37, D n = 102) CBD clearance 30/37 (81.1%) 84/102 (82.4%) 1.000 Postoperative ERCP among PP cases 5/37 (13.5%) 19/102 (18.6%) 0.611 †Fisher's exact test, two-tailed. ITT = intention-to-treat (all attempted cases). PP = per-protocol (successfully cannulated cases only). C = Choledochoscope group. D = Dormia group. Postoperative Complications The documented complication rate based on operative log entries was 1.3% (2/154) . Bile leak occurred in one patient in the choledochoscope group (1/41, 2.4%) and one in the Dormia group (1/113, 0.9%) ( p = 0.463); both were managed conservatively. No pancreatitis, biliary injuries, duodenal injuries, or bleeding events were documented in the operative log. The 30-day readmission rate for biliary complications was 1.9% ( n = 3). One patient was readmitted for a retained CBD stone, one for a gallbladder-bed collection managed with interventional radiology drainage, and one for persistent abdominal pain following ERCP stenting, treated conservatively. The mean length of hospital stay was 5.4 days (SD = 4.2). The majority of patients (65.6%, n = 101) required more than three days of hospitalisation, reflecting the complexity of managing concomitant cholecystitis and choledocholithiasis in the acute setting. Discussion Principal Findings This study compared choledochoscope-assisted and Dormia basket-only transcystic LCBDE in 154 patients undergoing emergency laparoscopic cholecystectomy for acute biliary presentations. The central finding is that no statistically significant difference was identified on any measured outcome: both techniques achieved comparable rates of cannulation success (~ 90%), per-protocol CBD clearance (~ 82%), postoperative ERCP (~ 20%), and bile leak (~ 1.3%). This finding has important practical implications for technique selection, training, and resource planning in acute-care surgical units. Interpretation of Key Findings The comparable cannulation success rates, using a primary-attempt strategy (90.2% vs 90.3%, p = 1.000), merit careful interpretation. These figures reflect success of the overall operative strategy — including rescue by a second instrument when the primary instrument failed — rather than the isolated technical performance of each instrument alone. This is a methodologically accepted approach when comparing treatment strategies rather than individual devices, and is consistent with how single-stage LCBDE is deployed in practice, but readers should be aware that true first-instrument cannulation success rates would be lower. Earlier versions of this dataset, prior to systematic variable coding, appeared to show large differences in cannulation success between groups — ranging from 75% to 91% depending on how cases of sequential instrument use were assigned. Once a consistent primary-attempt rule was applied (cases where the choledochoscope was the intended primary instrument classified to the choledochoscope group regardless of whether Dormia rescue was subsequently used), the apparent difference dissolved entirely. This serves as a methodological caution for future LCBDE comparative studies: technique assignment rules must be pre-specified and applied consistently to all cases including those with instrument switching. The comparable per-protocol CBD clearance rates (81.1% vs 82.4%) are consistent with published data for both techniques in mixed cohorts. Zhou et al. reported choledochoscope-assisted clearance rates of 88–92% in a larger retrospective series [ 3 ], and our result of 81.1% likely reflects the additional challenge of acute inflammatory anatomy — pericholecystic oedema, friable tissue, and restricted cystic duct mobility — that characterises emergency rather than elective cases. The Dormia group's 82.4% per-protocol clearance is notably higher than might be expected from earlier reports in mixed elective series, possibly reflecting surgeon-level selection of straightforward cases for the Dormia approach, or the utility of intraoperative saline flushing as an adjunct. The postoperative ERCP rates of approximately 20% in both groups merit contextualisation. This figure encompasses ERCPs performed for suspected retained stones (the majority, most of which were therapeutic), for bile leak management (one case), and cases where ERCP was performed on clinical suspicion but revealed no residual stone on endoscopic evaluation or subsequent EUS. The overall rate is consistent with published series in acute-care LCBDE [ 14 , 15 ], and the absence of a significant difference between groups confirms that neither technique confers a clinically meaningful advantage in ERCP avoidance in this setting. Saline flushing was employed in 25.0% of choledochoscope cannulation failures and 36.4% of Dormia failures, with procedural success in all flushed cases. This adjunct appears effective for small-calibre debris and sludge and does not require formal duct entry; its liberal use in cases of initial instrument failure is supported by these data. The Findings in Context The absence of significant outcome differences in this study does not imply that the two techniques are identical or interchangeable in all clinical contexts. Choledochoscope-assisted LCBDE is widely considered advantageous for difficult cases — multiple or impacted stones, complex anatomy, uncertain stone location — where direct intraductal visualisation offers diagnostic and therapeutic precision [ 10 , 15 ]. The Dormia basket's simplicity, shorter setup time, and universal availability make it the practical default in most acute-care scenarios, particularly where choledochoscope availability is inconsistent or surgeon experience with flexible choledochoscopy is limited. What the present data do support is that in an unselected, real-world acute-care emergency cohort, the pragmatic outcomes of both approaches — as measured by what ultimately happens to the patient — showed no statistically significant differences. A ~ 20% postoperative ERCP rate and ~ 82% per-protocol clearance were observed with both approaches when integrated into a systematic acute-care LCBDE programme. This supports the practice of adapting technique to available resources and intraoperative anatomy rather than committing to either approach categorically. Comparison with Existing Literature These findings are consistent with the broader body of evidence supporting single-stage transcystic LCBDE as a safe and effective alternative to staged ERCP-based management. Wu et al. [ 2 ] demonstrated shorter hospital stays and fewer complications with single-stage LCBDE versus ERCP + LC in elderly patients. The UK-wide P-ALiCE study by Tanase et al. [ 4 ] found transcystic LCBDE to be the preferred approach in 68% of cases with high clearance and low morbidity. Multicentre series by Zhang et al. [ 5 ], Xie et al. [ 6 ], and Wang et al. [ 7 ] have further validated the technique's safety and ductal clearance across large populations. Morton et al. [ 14 ] demonstrated that LCBDE by acute-care surgeons reduces time-to-treatment and cost compared with ERCP. These benchmarks support the overall safety and effectiveness of LCBDE as demonstrated in the present series. Directly comparative data between choledochoscope and Dormia basket approaches are sparse. El-Ghamry et al. [ 18 ] reported differences in operative times between approaches in a prospective series but did not compare these specific extraction modalities. Al-Ardah et al. [ 19 ] confirmed the safety of index-admission LCBDE without technique differentiation. Pogorelić et al. [ 20 ] demonstrated successful Dormia use in paediatric LCBDE without head-to-head comparison. The present study provides the most direct comparison to date of these two techniques in an acute-care emergency population. Clinical Implications For acute-care surgical units developing or expanding LCBDE programmes, these data have several practical implications. First, the absence of technique-level outcome differences supports a strategy of standardising to whichever approach is most reliably available and within the team's competency , rather than investing solely in choledochoscope infrastructure on the assumption of superiority. Second, the ~ 20% postoperative ERCP rate — comparable between both approaches — should be framed as an expected component of single-stage LCBDE practice rather than a failure: it represents residual stones appropriately identified by completion cholangiography and cleared endoscopically, avoiding the complications and delays of missed bile duct stones. Third, the documented complication rate of 1.3% based on operative log entries confirms that LCBDE can be safely integrated into emergency surgical workflows across teams of varying experience when supported by consistent technique, systematic completion imaging, and a clear postoperative ERCP protocol; acknowledging that late or externally managed events may not be fully captured in operative records. For centres where choledochoscope access is limited, these results provide direct evidence that Dormia basket-only LCBDE achieves comparable outcomes and should not be considered a lesser alternative. For centres with consistent choledochoscope availability and trained operators, the scope-assisted approach remains valuable for complex cases, with no detriment in routine cases. Limitations The retrospective design with intraoperative technique allocation prevents randomisation and limits causal conclusions. The operative log did not capture stone burden, CBD diameter, or detailed acute cholecystitis severity grade in a standardised format, preventing covariate adjustment or subgroup analysis by case complexity. The group size imbalance (41 vs 113) reflects real-world practice and reduces statistical power; a true modest difference between techniques — of the order of 5–8 percentage points in clearance — could not be reliably detected at this sample size. Complications were identified from operative documentation and may underestimate delayed or externally managed events not captured in the operative log; a systematic prospective complication register would have improved ascertainment. Finally, operator experience with each technique was not individually quantified, and surgeon-level effects may have contributed to outcomes. Future Directions Adequately powered prospective randomised controlled trials comparing choledochoscope-assisted and Dormia basket-only LCBDE in matched acute-care cohorts, stratified by stone burden and cystic duct anatomy, are required. Patient-level data including baseline CBD diameter, stone number and size, and acute cholecystitis severity grade should be collected prospectively to enable covariate-adjusted comparisons. Cost-effectiveness analyses incorporating device costs, operative time, and ERCP avoidance are needed to inform resource planning. Standardised training pathway data from programmes such as the LIBERTI initiative [10] would strengthen the evidence base for LCBDE competency frameworks across both techniques. Strengths and Limitations of this Study Strengths The primary strength of this study is its execution in a strictly acute-care environment — patients admitted as emergencies and operated on within the index admission — rather than the mixed elective and urgent populations that characterise most published LCBDE series. This setting adds real-world applicability to a literature dominated by elective data. The participation of eight consultant surgeons and their trainees across varying experience levels further enhances external validity by reflecting authentic acute-care operative teams. A second strength is the prospective operative log from which outcome data were derived, enabling systematic case-by-case verification. All ambiguous entries were adjudicated using pre-specified rules before statistical analysis, and three erroneous entries (one non-LCBDE case and two duplicates) were identified and excluded, improving dataset integrity over prior versions. This study represents, to our knowledge, the first direct comparison of Dormia basket-only and choledochoscope-assisted LCBDE in a purely acute-care context. Limitations The retrospective design limits causal inference; technique selection was surgeon-led and intraoperatively determined, introducing potential selection bias. The study cannot rule out the possibility that more complex cases were preferentially assigned to the choledochoscope group. The marked group size imbalance (41 vs 113) reflects real-world practice but reduces statistical power; the current sample is underpowered to detect modest true differences between techniques. Baseline demographics — particularly stone burden, CBD diameter, and acute cholecystitis severity grading — were not uniformly available from the operative log and could not be compared between groups. Complications were identified from operative documentation and may underestimate delayed or externally managed events; the reported rate of 1.3% should be interpreted as the documented rate from operative log entries rather than a comprehensive clinical incidence. Length of stay and 30-day readmission data were partially available and are reported descriptively. A formal cost analysis was not performed. Conclusions In this verified cohort of 154 patients undergoing emergency transcystic LCBDE, choledochoscope-assisted and Dormia basket-only approaches showed no statistically significant difference on any measured endpoint: cannulation success using a primary-attempt strategy (~ 90%), per-protocol CBD clearance (~ 82%), postoperative ERCP (~ 20%), and documented bile leak rate (~ 1.3%), with no biliary or duodenal injuries recorded. Single-stage transcystic LCBDE is safe and effective in an acute-care emergency setting regardless of technique. Technique selection should be guided by intraoperative anatomy, stone complexity, and locally available equipment and expertise rather than an assumption of technique-level superiority. These findings support the broader adoption of LCBDE in emergency surgical pathways and provide the first directly comparative data on these two approaches in a purely acute-care context. Prospective multicentre studies are warranted to confirm these findings and to establish evidence-based criteria for technique selection. Abbreviations ASA American Society of Anesthesiologists CBD common bile duct ERCP endoscopic retrograde cholangiopancreatography EUS endoscopic ultrasound HMC Hamad Medical Corporation IOC intraoperative cholangiography IQR interquartile range ITT intention-to-treat LC laparoscopic cholecystectomy LCBDE laparoscopic common bile duct exploration LOS length of stay MRCP magnetic resonance cholangiopancreatography PP per-protocol SD standard deviation SPSS Statistical Package for the Social Sciences STROBE Strengthening the Reporting of Observational Studies in Epidemiology. Declarations Ethics approval and consent to participate This study was approved by the Hamad Medical Corporation Medical Research Center (approval number: MRC-01-25-700) and was conducted in accordance with the Declaration of Helsinki. Patient consent for anonymised data use was obtained or waived in accordance with institutional policy. Consent for publication Not applicable. This manuscript contains no individual person’s data in any form. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Patient data were de-identified and managed in accordance with institutional data protection policies. Public sharing of the raw dataset is not permitted due to ethical and institutional restrictions. Competing interests The authors declare that they have no competing interests. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors’ contributions MQA conceived the study, oversaw data collection, contributed to data analysis and interpretation, and revised the manuscript critically. AAE contributed to data collection, literature review, and drafting of the manuscript. FAI contributed to data collection and verification. AZ contributed to study design and critical revision of the manuscript. AS conceived and designed the study, led data verification and statistical analysis, drafted and revised the manuscript, and is responsible for the overall integrity of the work. All authors read and approved the final manuscript. Acknowledgements The authors thank Dr. Mohamed Said Ghali (Hamad Medical Corporation) for assistance in obtaining ethical approval from the Medical Research Center, and Dr. Shameel Musthafa (Hamad Medical Corporation) for reviewing the study results. We also acknowledge Aya Mohamed Kheir Hassan Saad, Aya Mutasim Eltayeb Abdelgadir, Ayesha Amir, Fathima Thasleem Yoosuf, and Omer Wafi for their contributions to data collection. References Li J, Jin X, Ren J, et al. Global burden of gallbladder and biliary tract diseases: a systematic analysis for the Global Burden of Disease Study 2019. Gastroenterol Hepatol. 2022;37:1389–99. 10.1111/igh.15859 . Wu PH, Yu MW, Chuang SC, et al. Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones. J Gastrointest Surg. 2024;28:589–97. 10.1016/j.gassur.2024.02.026 . Zhou J, Chen Y, Yu S, et al. Comparison of one-stage and two-stage management for common bile duct stones and gallstones: a retrospective study. J Clin Gastroenterol. 2025;59:269–75. 10.1097/mcg.0000000000002009 . Tanase A, Dhanda A, Cramp M, et al. Laparoscopic common bile duct exploration: results from a prospective multi-centre UK-wide study (P-ALiCE). HPB. 2025;25:264–5. 10.1016/j.hpb.2023.07.139 . Zhang Z, Shao G, Li Y, et al. Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis. Surg Endosc. 2025;37:1700–9. 10.1007/s00464-022-09601-5 . Xie W, Ma Z, Zuo J, et al. The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: multicenter retrospective study. Langenbecks Arch Surg. 2025;408:57–65. 10.1007/s00423-023-02923-3 . Wang P, Song G, Xie W, et al. Comparison of one-step laparoscopy and two-step endolaparoscopy in the treatment of secondary choledocholithiasis: a multicenter retrospective clinical study. Technol Health Care. 2023;31:1333–42. 10.3233/THC-220610 . Rauh J, Dantes G, Wallace M, et al. Transcystic laparoscopic common bile duct exploration for pediatric patients with choledocholithiasis: a multicenter study. J Pediatr Surg. 2024;59:389–92. 10.1016/j.jpedsurg.2023.10.046 . Patterson IW, Niebler JAP, Cambronero GE, et al. Spare the needle, discharge the child: trending post-operative labs after laparoscopic common bile duct exploration in pediatric patients is not helpful. Am Surg. 2024;90:56–65. 10.1177/00031348241227198 . VanDruff VN, Santos BF, Kuchta K, et al. The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis. Surg Endosc. 2024;38:931–41. 10.1007/s00464-023-10480-5 . World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191–4. 10.1001/jama.2013.281053 . Yokoe M, Hata I, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:41–54. 10.1002/jhbp.515 . McNamee MM, Stolz MP, Harvell RT, et al. Management of choledocholithiasis in a community hospital: laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography. Am Surg. 2024;90:145–52. 10.1177/00031348241241626 . Morton A, Cralley A, Brooke-Sanchez M, et al. Laparoscopic common bile duct exploration by acute care surgeons saves time and money compared to ERCP. Am J Surg. 2022;116:119. 10.1016/j.amjsurg.2022.03.026 . Yan Y, Sha Y, Yuan W, et al. One-stage versus two-stage management for acute cholecystitis associated with common bile duct stones: a retrospective cohort study. Surg Endosc. 2022;36:920–9. 10.1007/s00464-021-08349-6 . Zou Q, Ding Y, Li CS, et al. A randomized controlled trial of emergency LCBDE + LC and ERCP + LC in the treatment of choledocholithiasis with acute cholangitis. Wideochir Inne Tech Maloinwazyjne. 2022;17:156–62. 10.5114/wiitm.2021.108214 . Zhu J, Zhang Y, Du P, et al. Systematic review and meta-analysis of laparoscopic common bile duct exploration in patients with previous failed endoscopic retrograde cholangiopancreatography. Surg Laparosc Endosc Percutan Tech. 2021;31:654–62. 10.1097/SLE.0000000000000949 . El Ghamry EGE, El Sheikh M, Abdelhady H, et al. An auspicious experience with laparoscopic common bile duct exploration: a prospective study. Egypt J Surg. 2019;38:459–70. 10.4103/ejs.ejs_36_19 . Al-Ardah MI, Barnett RE, Rotennburg H, et al. Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years. Langenbecks Arch Surg. 2023;408:87–95. 10.1007/s00423-023-02773-z . Pogorelić Z, Lovrić M, Jukić M, et al. The laparoscopic cholecystectomy and common bile duct exploration: single-step treatment of pediatric cholelithiasis and choledocholithiasis. Child (Basel). 2022;9:1583. 10.3390/children9101583 . Additional Declarations No competing interests reported. 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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-9468228","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633529939,"identity":"515dc11e-766e-4b6e-9945-4a12e16b19ba","order_by":0,"name":"Mohammed Qaid Al Obahi","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Qaid Al","lastName":"Obahi","suffix":""},{"id":633529940,"identity":"93c85d08-0a8c-4f1f-8a75-efea6cce41d7","order_by":1,"name":"Ayah A. Eyalawwad","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Ayah","middleName":"A.","lastName":"Eyalawwad","suffix":""},{"id":633529941,"identity":"5a1ad059-9944-4497-9817-866ff564e5f5","order_by":2,"name":"Fajer Al-Ishaq","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Fajer","middleName":"","lastName":"Al-Ishaq","suffix":""},{"id":633529942,"identity":"42402098-c35c-48f1-a1fb-7cbcc525f44c","order_by":3,"name":"Ahmad Zarour","email":"","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":false,"prefix":"","firstName":"Ahmad","middleName":"","lastName":"Zarour","suffix":""},{"id":633529943,"identity":"3065d26f-1ccd-4a30-a6ec-0e70ff4a969d","order_by":4,"name":"Azhar Shabbir","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABN0lEQVRIie2RP0vDQBTAXxGcrma9UKpf4UKg2G+T0KFLUMQlQjyuFDoZsyZY6leIS+eEg7ikcY00Q110TRGkLmKTgtom4upwP7g/3N2P9949AIHgX4LKWQOMIADz+7zBNiv+Q4m3lWLgqvNDgcaoqlTCSM4sfDWBnkg3dsgvJpenZG6HTysrazut4csih2O6o+Ag6ckx8HOcJVo4m953/SzpqSh6Vr1xpAzcmsTCKyIzCHSWGiQcTCNCUqPTgn2u+6mmDFFVOeJIfWdA9dtSGW8UefVRKP1lnUIi1FlH2Vs/KBRmlQpujgrFqI2ixKjTZYTrd0UtLAqIXNTSvOaq5xpnnkuwzLaVw4dYfWQm1Sdzmy+ZRclB+WNvvO3gvp/nJpUqfSnT+9pxKBtUd/UbdFcRCAQCAXwCxPeAl5yLJ3oAAAAASUVORK5CYII=","orcid":"","institution":"Hamad Medical Corporation","correspondingAuthor":true,"prefix":"","firstName":"Azhar","middleName":"","lastName":"Shabbir","suffix":""}],"badges":[],"createdAt":"2026-04-20 07:12:46","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9468228/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9468228/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108411231,"identity":"12e43a57-f582-40a5-b932-0bf5509de85e","added_by":"auto","created_at":"2026-05-04 10:20:48","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":765987,"visible":true,"origin":"","legend":"\u003cp\u003ePatient flow diagram. Of 154 patients undergoing attempted transcystic LCBDE, 41 (26.6%) were in the Choledochoscope group and 113 (73.4%) in the Dormia group. Cannulation was successful in 37/41 and 102/113 respectively. Per-protocol CBD clearance was achieved in 30/37 and 84/102 respectively. Postoperative ERCP was performed in 8/41 and 23/113 respectively.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9468228/v1/60491db5fe2e00117fbccddd.jpeg"},{"id":108411232,"identity":"7baecd20-1f70-48f3-ae26-2f808d63f8eb","added_by":"auto","created_at":"2026-05-04 10:20:48","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":595598,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of intention-to-treat and per-protocol outcomes by technique group. Bar chart showing CBD clearance and postoperative ERCP rates under ITT (Choledochoscope: clearance 75.6%, ERCP 19.5%; Dormia: clearance 77.9%, ERCP 20.4%) and PP (Choledochoscope: clearance 81.1%; Dormia: clearance 82.4%) frameworks. All differences non-significant (Fisher's exact test, all p≥0.611).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9468228/v1/9a99b2c734a9ba2f6c6343e3.jpeg"},{"id":108976437,"identity":"c9a235bd-20ae-4479-919a-c44db245b960","added_by":"auto","created_at":"2026-05-11 11:20:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1672021,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9468228/v1/a142a54d-b101-4910-8e4d-865fb57683c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Transcystic Laparoscopic Common Bile Duct Exploration (LCBDE) Combined with Laparoscopic Cholecystectomy for Acute Biliary Presentations: A Comparative Cohort Study of Choledochoscope-Assisted and Dormia Basket-Only Techniques","fulltext":[{"header":"Article Summary","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known on this topic\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull; Single-stage transcystic LCBDE combined with LC reduces staged ERCP-based management and is safe in elective and mixed cohorts.\u003c/p\u003e\n\u003cp\u003e\u0026bull; Choledochoscope-assisted extraction enables direct stone visualisation; Dormia basket-only extraction requires a simpler instrument profile.\u003c/p\u003e\n\u003cp\u003e\u0026bull; No large comparative study has examined these two techniques specifically in a purely acute-care emergency surgical setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this study adds\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026bull; In a verified cohort of 154 emergency LCBDE cases, choledochoscope-assisted and Dormia basket-only techniques showed no statistically significant difference on any measured outcome: ~90% cannulation success using a primary-attempt strategy, ~82% per-protocol CBD clearance, ~20% postoperative ERCP, and ~1.3% documented bile leak rate. Diagnoses were grouped into acute cholecystitis and biliary colic categories based on operative and clinical documentation.\u003c/p\u003e\n\u003cp\u003e\u0026bull; No statistically significant difference was found on any measured outcome (all p \u0026ge; 0.463).\u003c/p\u003e\n\u003cp\u003e\u0026bull; Both techniques are safe and viable in acute-care pathways; choice should be individualised to anatomy and available equipment.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eBiliary tract disease, including cholelithiasis and concomitant choledocholithiasis, is among the most common causes of emergency surgical admission worldwide, contributing substantially to morbidity and healthcare expenditure [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The conventional two-stage management pathway \u0026mdash; endoscopic retrograde cholangiopancreatography (ERCP) for ductal clearance followed by interval laparoscopic cholecystectomy (LC) \u0026mdash; is effective but carries the cumulative risks of procedure-specific complications (post-ERCP pancreatitis, bleeding, perforation), repeated general anaesthesia, prolonged hospitalisation, and the logistical burden of a staged admission [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSingle-stage management \u0026mdash; laparoscopic common bile duct exploration (LCBDE) performed concurrently with LC \u0026mdash; has attracted increasing interest as a means of achieving definitive biliary clearance in a single operative episode. Multicentre series, randomised trials, and systematic reviews have consistently demonstrated high clearance rates and favourable perioperative safety profiles for transcystic LCBDE [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with feasibility confirmed even in paediatric cohorts and after prior failed ERCP [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Adoption nonetheless remains limited in many centres, driven by the perceived need for specialised endoscopic equipment, a learning curve, and limited exposure during surgical training [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo principal transcystic techniques are in current use. Choledochoscope-assisted LCBDE employs a flexible miniature endoscope introduced through the cystic ductotomy, enabling direct intraductal visualisation and targeted stone retrieval. Dormia basket-only LCBDE relies on fluoroscopic guidance to deploy a four-wire stone retrieval basket without endoscopic visualisation. Each technique carries theoretical advantages: the choledochoscope offers precision and visual confirmation of clearance; the Dormia basket is simpler, faster to set up, and available in virtually all laparoscopic suites. In practice, both are in routine use and technique selection is often opportunistic, governed by instrument availability and surgeon familiarity rather than evidence-based criteria.\u003c/p\u003e \u003cp\u003eExisting comparative data on these two approaches are sparse, and no study has specifically evaluated them in a purely acute-care setting \u0026mdash; where inflammatory tissue planes, pericholecystic oedema, and friable cystic ducts may differentially affect the performance of each instrument. The present study aimed to compare outcomes of choledochoscope-assisted and Dormia basket-only transcystic LCBDE in patients undergoing emergency LC for acute cholecystitis or severe biliary colic, using both ITT and PP analytical frameworks. The study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003e This retrospective observational cohort study was conducted at Hamad Medical Corporation (HMC), a tertiary referral centre with a dedicated Acute Care Surgery Unit serving as the primary emergency surgical facility for four satellite hospitals in Doha, Qatar. The study period spanned January 1, 2020 to December 31, 2021. The study protocol was approved by the HMC Medical Research Center (Approval No. MRC-01-25-700). All procedures were performed in accordance with the Declaration of Helsinki [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Patient consent for anonymised data use was obtained or waived according to institutional policy.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDataset Verification\u003c/h3\u003e\n\u003cp\u003eData were extracted from a prospectively maintained operative log supplemented by the institutional electronic medical record. Prior to any statistical analysis, the complete dataset underwent formal row-level verification. Three entries were excluded: one patient who underwent laparoscopic cholecystectomy with intraoperative cholangiography only (LC\u0026thinsp;+\u0026thinsp;IOC) without CBDE and therefore did not meet the inclusion criterion of attempted LCBDE; and two duplicate entries identified by identical hospital numbers. For each duplicate pair, the entry with the more complete outcome data was retained. The verified final cohort comprised 154 patients.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eAdmission to the Acute Care Surgery Unit with a diagnosis of acute cholecystitis confirmed according to Tokyo Guidelines 2018 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] (clinical, laboratory, and imaging criteria) or severe biliary colic; presence of CBD stones confirmed by preoperative imaging (abdominal ultrasound, MRCP, or EUS) or intraoperative cholangiography; performance of attempted transcystic LCBDE during the same LC; and cholecystectomy completed within the index admission within 7 days of symptom onset.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExclusion Criteria\u003c/h3\u003e\n\u003cp\u003ePrevious biliary surgery (prior cholecystectomy or biliary reconstruction); severe comorbidity precluding laparoscopy (ASA class IV\u0026ndash;V); incomplete operative data; management by an ERCP-first approach; and cases in which LC\u0026thinsp;+\u0026thinsp;IOC was performed without any attempted LCBDE.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTechnique Group Assignment\u003c/h2\u003e \u003cp\u003ePatients were assigned to technique groups based on the primary instrument attempted at the time of LCBDE. Cases in which the choledochoscope was the first instrument attempted \u0026mdash; whether successful or not, and including cases where a Dormia basket was subsequently used after choledochoscope failure \u0026mdash; were assigned to the Choledochoscope group. Cases in which only a Dormia basket was attempted were assigned to the Dormia group. This primary-attempt rule was applied consistently across all 154 cases, including those with entries of 'YES/FAILED' in the choledochoscope column.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eVariable Definitions\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eCannulation success\u003c/strong\u003e \u003cp\u003esuccessful entry of the cystic duct by any instrument attempted within the operative strategy, enabling performance of cholangiography and stone extraction. Cases where the choledochoscope failed but the Dormia basket subsequently achieved access were classified as cannulation success within the Choledochoscope group (primary-attempt strategy). This definition reflects procedural success of the treatment approach rather than isolated instrument performance.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eIntraoperative CBD clearance\u003c/strong\u003e \u003cp\u003econfirmed absence of filling defects on completion cholangiogram. Cases where saline flushing was used as an adjunct and subsequently achieved radiological clearance were classified as cleared; the flush represents an intraoperative manoeuvre and its success constitutes procedural clearance. Stones retained at completion of the operative procedure \u0026mdash; regardless of subsequent ERCP outcome \u0026mdash; were classified as retained (intraoperative outcome only).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePostoperative ERCP\u003c/strong\u003e \u003cp\u003eany endoscopic retrograde cholangiopancreatography performed after the index operation, regardless of indication (retained stones, bile leak) or result (stone confirmed or not). Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) used for imaging only, without therapeutic endoscopic intervention, were not classified as postoperative ERCP.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eComplications\u003c/strong\u003e \u003cp\u003eexplicitly documented events in the operative log or clinical record, including bile leak, pancreatitis, biliary injury, duodenal injury, and bleeding.\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eSurgical Technique\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLaparoscopic Cholecystectomy\u003c/h2\u003e \u003cp\u003ePerformed using a standard four-port technique. The critical view of safety was obtained before division of the cystic duct and artery in all cases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative Cholangiography (IOC)\u003c/h2\u003e \u003cp\u003eIOC was routinely performed via cystic duct cannulation using a cholangiography catheter to confirm the presence, number, and size of CBD stones and to delineate biliary ductal anatomy prior to LCBDE.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCholedochoscope-Assisted LCBDE\u003c/h2\u003e \u003cp\u003eA 3 mm flexible choledochoscope was introduced through a cystic ductotomy under direct vision. Stones were identified endoscopically and retrieved using a Dormia basket passed through the working channel under endoscopic guidance. Ductal clearance was confirmed visually where possible and by repeat fluoroscopic cholangiography.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eDormia Basket-Only LCBDE\u003c/h2\u003e \u003cp\u003eA four-wire Dormia basket was introduced through the cystic duct under fluoroscopic guidance without direct endoscopic visualisation. Stones were captured and extracted through multiple passes as required. Clearance was confirmed by cholangiography.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSaline Flushing\u003c/h2\u003e \u003cp\u003ePressurised saline flushing through the cystic duct was performed in cases of suspected residual sludge or debris, particularly following unsuccessful cannulation attempts or after basket passes. Clearance was confirmed fluoroscopically.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTechnique Selection\u003c/h2\u003e \u003cp\u003eTechnique selection was an intraoperative decision made by the operating surgeon, based on cystic duct diameter and anatomy, stone burden, instrument availability, and individual experience. The study was conducted with the participation of eight consultant surgeons and supervised surgical trainees, representing variable levels of LCBDE experience in a real-world acute-care environment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePostoperative Follow-up\u003c/h2\u003e \u003cp\u003ePatients were followed up clinically and with imaging as indicated for a minimum of three months postoperatively. ERCP was performed if clinical findings, biochemistry, or imaging suggested retained CBD stones or biliary complication. EUS or MRCP were used for diagnostic evaluation in selected cases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eCategorical variables are presented as frequencies and percentages; continuous variables as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range, IQR). Between-group comparisons used Fisher's exact test for categorical data and the independent-samples \u003cem\u003et\u003c/em\u003e-test or Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test for continuous variables, as appropriate. A \u003cem\u003ep\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using SPSS v25 (IBM Corp., Armonk, NY, USA). Analyses were performed according to both ITT (all attempted cases) and PP (successfully cannulated cases only) frameworks. The study was conducted and reported in accordance with the STROBE guidelines for observational studies. Artificial intelligence language model assistance (Claude, Anthropic) was used in manuscript drafting and editing; all data analysis, clinical interpretation, and final content decisions were made by the authors.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Flow and Baseline Data\u003c/h2\u003e \u003cp\u003eThe final study cohort comprised \u003cb\u003e154 patients\u003c/b\u003e who underwent attempted transcystic LCBDE during emergency laparoscopic cholecystectomy between January 2020 and December 2021. Three cases were excluded during dataset verification (one LC\u0026thinsp;+\u0026thinsp;IOC-only case without LCBDE attempt; two duplicate hospital-number entries), yielding the 154-patient cohort reported here.\u003c/p\u003e \u003cp\u003eThe mean patient age was 38.8 years (SD\u0026thinsp;=\u0026thinsp;12.3), with a female predominance (64.6%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;100). The majority were classified ASA 2 (35.1%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;54) or ASA 2E (28.6%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;44). The predominant surgical indications were acute cholecystitis (53.2%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;82) and severe biliary colic (46.8%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;72). Diagnoses were grouped into these two categories based on operative documentation and clinical record review.\u003c/p\u003e \u003cp\u003eCholedochoscope-assisted LCBDE was the primary attempted technique in \u003cb\u003e41 patients (26.6%)\u003c/b\u003e, and Dormia basket-only LCBDE in \u003cb\u003e113 patients (73.4%)\u003c/b\u003e. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the patient flow from attempted LCBDE through cannulation, ductal clearance, and postoperative interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eOperative Outcomes\u003c/h2\u003e \u003cp\u003eUsing a primary-attempt strategy, cannulation success was \u003cb\u003e90.2% in the choledochoscope group (37/41)\u003c/b\u003e and \u003cb\u003e90.3% in the Dormia group (102/113)\u003c/b\u003e (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Cannulation failed in 4 (9.8%) and 11 (9.7%) patients, respectively. Among the choledochoscope failures, a Dormia basket was subsequently attempted in 4 cases and achieved successful access in 3; for analytical purposes, these 4 cases remain within the choledochoscope group per the primary-attempt rule.\u003c/p\u003e \u003cp\u003eAmong successfully cannulated patients (per-protocol analysis), intraoperative CBD clearance was achieved in \u003cb\u003e30 of 37 (81.1%)\u003c/b\u003e in the choledochoscope group and \u003cb\u003e84 of 102 (82.4%)\u003c/b\u003e in the Dormia group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Residual filling defects were identified at completion cholangiography in 7 (18.9%) and 18 (17.6%) patients, respectively. In the ITT analysis, clearance was 75.6% (31/41) versus 77.9% (88/113) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.829).\u003c/p\u003e \u003cp\u003eSaline flushing was employed as an adjunct in cases of failed cannulation \u0026mdash; 1 of 4 choledochoscope failures (25.0%) and 4 of 11 Dormia failures (36.4%) \u0026mdash; resulting in successful completion cholangiography without formal ductal entry in those cases. ITT clearance figures include these saline-flush successes, consistent with the predefined intraoperative clearance definition (any confirmed absence of filling defects on completion cholangiogram, irrespective of the method used to achieve it).\u003c/p\u003e \u003cp\u003eOverall, \u003cb\u003e31 of 154 patients (20.1%)\u003c/b\u003e required postoperative ERCP. In the choledochoscope group, 8 patients (19.5%) underwent postoperative ERCP; in the Dormia group, 23 (20.4%) required ERCP (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Among patients in whom cannulation failed, ERCP was required in 2 of 4 (50.0%) in the choledochoscope group and 5 of 11 (45.5%) in the Dormia group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). In most cases, ERCP was performed for suspected retained CBD stones and was therapeutic; a small number had negative findings on ERCP or subsequent EUS, confirming that intraoperative cholangiography carries a modest false-positive rate for stone detection in this setting.\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\u003eOperative and Postoperative Outcomes by Technique Group (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholedochoscope (n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDormia Basket (n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u0026dagger;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannulation success\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37/41 (90.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e102/113 (90.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCannulation failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4/41 (9.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11/113 (9.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBD clearance \u0026mdash; ITT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31/41 (75.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88/113 (77.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBD clearance \u0026mdash; PP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30/37 (81.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84/102 (82.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetained stone \u0026mdash; ITT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10/41 (24.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25/113 (22.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative ERCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8/41 (19.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23/113 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eERCP after cannulation failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2/4 (50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5/11 (45.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaline flushing among failures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/4 (25.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4/11 (36.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile leak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1/41 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1/113 (0.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.463\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePancreatitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0/41 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0/113 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiliary injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0/41 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0/113 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuodenal injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0/41 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0/113 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0/41 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0/113 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e*PP\u0026thinsp;=\u0026thinsp;per-protocol analysis (successfully cannulated cases only: choledochoscope n\u0026thinsp;=\u0026thinsp;37, Dormia n\u0026thinsp;=\u0026thinsp;102). \u0026dagger;All p-values from Fisher's exact test, two-tailed. ITT\u0026thinsp;=\u0026thinsp;intention-to-treat. ERCP\u0026thinsp;=\u0026thinsp;endoscopic retrograde cholangiopancreatography. CBD\u0026thinsp;=\u0026thinsp;common bile duct.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eITT and Per-Protocol Analyses\u003c/h2\u003e \u003cp\u003eIn the ITT analysis, overall CBD clearance was 75.6% for the choledochoscope group and 77.9% for the Dormia group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.829). Postoperative ERCP was required in 19.5% versus 20.4% (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). In the PP analysis restricted to successfully cannulated cases, CBD clearance was 81.1% and 82.4% respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Postoperative ERCP among PP cases was 13.5% (5/37) versus 18.6% (19/102) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.611). Results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. No significant differences were identified between groups in either analytical framework.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntention-to-Treat and Per-Protocol Analysis (n\u0026thinsp;=\u0026thinsp;154)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCholedochoscope\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDormia Basket\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u0026dagger;\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eITT analysis (all attempted: C n\u0026thinsp;=\u0026thinsp;41, D n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBD clearance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31/41 (75.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88/113 (77.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.829\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative ERCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8/41 (19.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23/113 (20.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePP analysis (cannulated cases: C n\u0026thinsp;=\u0026thinsp;37, D n\u0026thinsp;=\u0026thinsp;102)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCBD clearance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30/37 (81.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e84/102 (82.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative ERCP among PP cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5/37 (13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19/102 (18.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.611\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026dagger;Fisher's exact test, two-tailed. ITT\u0026thinsp;=\u0026thinsp;intention-to-treat (all attempted cases). PP\u0026thinsp;=\u0026thinsp;per-protocol (successfully cannulated cases only). C\u0026thinsp;=\u0026thinsp;Choledochoscope group. D\u0026thinsp;=\u0026thinsp;Dormia group.\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003ePostoperative Complications\u003c/h2\u003e \u003cp\u003eThe documented complication rate based on operative log entries was \u003cb\u003e1.3% (2/154)\u003c/b\u003e. Bile leak occurred in one patient in the choledochoscope group (1/41, 2.4%) and one in the Dormia group (1/113, 0.9%) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.463); both were managed conservatively. No pancreatitis, biliary injuries, duodenal injuries, or bleeding events were documented in the operative log.\u003c/p\u003e \u003cp\u003eThe 30-day readmission rate for biliary complications was 1.9% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3). One patient was readmitted for a retained CBD stone, one for a gallbladder-bed collection managed with interventional radiology drainage, and one for persistent abdominal pain following ERCP stenting, treated conservatively. The mean length of hospital stay was 5.4 days (SD\u0026thinsp;=\u0026thinsp;4.2). The majority of patients (65.6%, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;101) required more than three days of hospitalisation, reflecting the complexity of managing concomitant cholecystitis and choledocholithiasis in the acute setting.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003ePrincipal Findings\u003c/h2\u003e \u003cp\u003eThis study compared choledochoscope-assisted and Dormia basket-only transcystic LCBDE in 154 patients undergoing emergency laparoscopic cholecystectomy for acute biliary presentations. The central finding is that no statistically significant difference was identified on any measured outcome: both techniques achieved comparable rates of cannulation success (~\u0026thinsp;90%), per-protocol CBD clearance (~\u0026thinsp;82%), postoperative ERCP (~\u0026thinsp;20%), and bile leak (~\u0026thinsp;1.3%). This finding has important practical implications for technique selection, training, and resource planning in acute-care surgical units.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eInterpretation of Key Findings\u003c/h2\u003e \u003cp\u003eThe comparable cannulation success rates, using a primary-attempt strategy (90.2% vs 90.3%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000), merit careful interpretation. These figures reflect success of the overall operative strategy \u0026mdash; including rescue by a second instrument when the primary instrument failed \u0026mdash; rather than the isolated technical performance of each instrument alone. This is a methodologically accepted approach when comparing treatment strategies rather than individual devices, and is consistent with how single-stage LCBDE is deployed in practice, but readers should be aware that true first-instrument cannulation success rates would be lower. Earlier versions of this dataset, prior to systematic variable coding, appeared to show large differences in cannulation success between groups \u0026mdash; ranging from 75% to 91% depending on how cases of sequential instrument use were assigned. Once a consistent primary-attempt rule was applied (cases where the choledochoscope was the intended primary instrument classified to the choledochoscope group regardless of whether Dormia rescue was subsequently used), the apparent difference dissolved entirely. This serves as a methodological caution for future LCBDE comparative studies: technique assignment rules must be pre-specified and applied consistently to all cases including those with instrument switching.\u003c/p\u003e \u003cp\u003eThe comparable per-protocol CBD clearance rates (81.1% vs 82.4%) are consistent with published data for both techniques in mixed cohorts. Zhou et al. reported choledochoscope-assisted clearance rates of 88\u0026ndash;92% in a larger retrospective series [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and our result of 81.1% likely reflects the additional challenge of acute inflammatory anatomy \u0026mdash; pericholecystic oedema, friable tissue, and restricted cystic duct mobility \u0026mdash; that characterises emergency rather than elective cases. The Dormia group's 82.4% per-protocol clearance is notably higher than might be expected from earlier reports in mixed elective series, possibly reflecting surgeon-level selection of straightforward cases for the Dormia approach, or the utility of intraoperative saline flushing as an adjunct.\u003c/p\u003e \u003cp\u003eThe postoperative ERCP rates of approximately 20% in both groups merit contextualisation. This figure encompasses ERCPs performed for suspected retained stones (the majority, most of which were therapeutic), for bile leak management (one case), and cases where ERCP was performed on clinical suspicion but revealed no residual stone on endoscopic evaluation or subsequent EUS. The overall rate is consistent with published series in acute-care LCBDE [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], and the absence of a significant difference between groups confirms that neither technique confers a clinically meaningful advantage in ERCP avoidance in this setting.\u003c/p\u003e \u003cp\u003eSaline flushing was employed in 25.0% of choledochoscope cannulation failures and 36.4% of Dormia failures, with procedural success in all flushed cases. This adjunct appears effective for small-calibre debris and sludge and does not require formal duct entry; its liberal use in cases of initial instrument failure is supported by these data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003eThe Findings in Context\u003c/h2\u003e \u003cp\u003eThe absence of significant outcome differences in this study does not imply that the two techniques are identical or interchangeable in all clinical contexts. Choledochoscope-assisted LCBDE is widely considered advantageous for difficult cases \u0026mdash; multiple or impacted stones, complex anatomy, uncertain stone location \u0026mdash; where direct intraductal visualisation offers diagnostic and therapeutic precision [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The Dormia basket's simplicity, shorter setup time, and universal availability make it the practical default in most acute-care scenarios, particularly where choledochoscope availability is inconsistent or surgeon experience with flexible choledochoscopy is limited.\u003c/p\u003e \u003cp\u003eWhat the present data do support is that in an unselected, real-world acute-care emergency cohort, the pragmatic outcomes of both approaches \u0026mdash; as measured by what ultimately happens to the patient \u0026mdash; showed no statistically significant differences. A\u0026thinsp;~\u0026thinsp;20% postoperative ERCP rate and ~\u0026thinsp;82% per-protocol clearance were observed with both approaches when integrated into a systematic acute-care LCBDE programme. This supports the practice of adapting technique to available resources and intraoperative anatomy rather than committing to either approach categorically.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eComparison with Existing Literature\u003c/h2\u003e \u003cp\u003eThese findings are consistent with the broader body of evidence supporting single-stage transcystic LCBDE as a safe and effective alternative to staged ERCP-based management. Wu et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] demonstrated shorter hospital stays and fewer complications with single-stage LCBDE versus ERCP\u0026thinsp;+\u0026thinsp;LC in elderly patients. The UK-wide P-ALiCE study by Tanase et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] found transcystic LCBDE to be the preferred approach in 68% of cases with high clearance and low morbidity. Multicentre series by Zhang et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], Xie et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], and Wang et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] have further validated the technique's safety and ductal clearance across large populations. Morton et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] demonstrated that LCBDE by acute-care surgeons reduces time-to-treatment and cost compared with ERCP. These benchmarks support the overall safety and effectiveness of LCBDE as demonstrated in the present series.\u003c/p\u003e \u003cp\u003eDirectly comparative data between choledochoscope and Dormia basket approaches are sparse. El-Ghamry et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported differences in operative times between approaches in a prospective series but did not compare these specific extraction modalities. Al-Ardah et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] confirmed the safety of index-admission LCBDE without technique differentiation. Pogorelić et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] demonstrated successful Dormia use in paediatric LCBDE without head-to-head comparison. The present study provides the most direct comparison to date of these two techniques in an acute-care emergency population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eFor acute-care surgical units developing or expanding LCBDE programmes, these data have several practical implications. First, the absence of technique-level outcome differences supports a strategy of \u003cb\u003estandardising to whichever approach is most reliably available and within the team's competency\u003c/b\u003e, rather than investing solely in choledochoscope infrastructure on the assumption of superiority. Second, the ~\u0026thinsp;20% postoperative ERCP rate \u0026mdash; comparable between both approaches \u0026mdash; should be framed as an expected component of single-stage LCBDE practice rather than a failure: it represents residual stones appropriately identified by completion cholangiography and cleared endoscopically, avoiding the complications and delays of missed bile duct stones. Third, the documented complication rate of 1.3% based on operative log entries confirms that LCBDE can be safely integrated into emergency surgical workflows across teams of varying experience when supported by consistent technique, systematic completion imaging, and a clear postoperative ERCP protocol; acknowledging that late or externally managed events may not be fully captured in operative records.\u003c/p\u003e \u003cp\u003eFor centres where choledochoscope access is limited, these results provide direct evidence that Dormia basket-only LCBDE achieves comparable outcomes and should not be considered a lesser alternative. For centres with consistent choledochoscope availability and trained operators, the scope-assisted approach remains valuable for complex cases, with no detriment in routine cases.\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThe retrospective design with intraoperative technique allocation prevents randomisation and limits causal conclusions. The operative log did not capture stone burden, CBD diameter, or detailed acute cholecystitis severity grade in a standardised format, preventing covariate adjustment or subgroup analysis by case complexity. The group size imbalance (41 vs 113) reflects real-world practice and reduces statistical power; a true modest difference between techniques \u0026mdash; of the order of 5\u0026ndash;8 percentage points in clearance \u0026mdash; could not be reliably detected at this sample size. Complications were identified from operative documentation and may underestimate delayed or externally managed events not captured in the operative log; a systematic prospective complication register would have improved ascertainment. Finally, operator experience with each technique was not individually quantified, and surgeon-level effects may have contributed to outcomes.\u003c/p\u003e\n\u003ch2\u003eFuture Directions\u003c/h2\u003e\n\u003cp\u003eAdequately powered prospective randomised controlled trials comparing choledochoscope-assisted and Dormia basket-only LCBDE in matched acute-care cohorts, stratified by stone burden and cystic duct anatomy, are required. Patient-level data including baseline CBD diameter, stone number and size, and acute cholecystitis severity grade should be collected prospectively to enable covariate-adjusted comparisons. Cost-effectiveness analyses incorporating device costs, operative time, and ERCP avoidance are needed to inform resource planning. Standardised training pathway data from programmes such as the LIBERTI initiative [10] would strengthen the evidence base for LCBDE competency frameworks across both techniques.\u003c/p\u003e"},{"header":"Strengths and Limitations of this Study","content":"\u003ch2\u003eStrengths\u003c/h2\u003e\n\u003cp\u003eThe primary strength of this study is its execution in a strictly acute-care environment \u0026mdash; patients admitted as emergencies and operated on within the index admission \u0026mdash; rather than the mixed elective and urgent populations that characterise most published LCBDE series. This setting adds real-world applicability to a literature dominated by elective data. The participation of eight consultant surgeons and their trainees across varying experience levels further enhances external validity by reflecting authentic acute-care operative teams.\u003c/p\u003e\n\u003cp\u003eA second strength is the prospective operative log from which outcome data were derived, enabling systematic case-by-case verification. All ambiguous entries were adjudicated using pre-specified rules before statistical analysis, and three erroneous entries (one non-LCBDE case and two duplicates) were identified and excluded, improving dataset integrity over prior versions. This study represents, to our knowledge, the first direct comparison of Dormia basket-only and choledochoscope-assisted LCBDE in a purely acute-care context.\u003c/p\u003e\n\u003ch2\u003eLimitations\u003c/h2\u003e\n\u003cp\u003eThe retrospective design limits causal inference; technique selection was surgeon-led and intraoperatively determined, introducing potential selection bias. The study cannot rule out the possibility that more complex cases were preferentially assigned to the choledochoscope group. The marked group size imbalance (41 vs 113) reflects real-world practice but reduces statistical power; the current sample is underpowered to detect modest true differences between techniques. Baseline demographics \u0026mdash; particularly stone burden, CBD diameter, and acute cholecystitis severity grading \u0026mdash; were not uniformly available from the operative log and could not be compared between groups. Complications were identified from operative documentation and may underestimate delayed or externally managed events; the reported rate of 1.3% should be interpreted as the documented rate from operative log entries rather than a comprehensive clinical incidence. Length of stay and 30-day readmission data were partially available and are reported descriptively. A formal cost analysis was not performed.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this verified cohort of 154 patients undergoing emergency transcystic LCBDE, choledochoscope-assisted and Dormia basket-only approaches showed no statistically significant difference on any measured endpoint: cannulation success using a primary-attempt strategy (~\u0026thinsp;90%), per-protocol CBD clearance (~\u0026thinsp;82%), postoperative ERCP (~\u0026thinsp;20%), and documented bile leak rate (~\u0026thinsp;1.3%), with no biliary or duodenal injuries recorded. Single-stage transcystic LCBDE is safe and effective in an acute-care emergency setting regardless of technique. Technique selection should be guided by intraoperative anatomy, stone complexity, and locally available equipment and expertise rather than an assumption of technique-level superiority. These findings support the broader adoption of LCBDE in emergency surgical pathways and provide the first directly comparative data on these two approaches in a purely acute-care context. Prospective multicentre studies are warranted to confirm these findings and to establish evidence-based criteria for technique selection.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCBD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecommon bile duct\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eERCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eendoscopic retrograde cholangiopancreatography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eendoscopic ultrasound\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHamad Medical Corporation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIOC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintraoperative cholangiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eITT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintention-to-treat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elaparoscopic cholecystectomy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLCBDE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elaparoscopic common bile duct exploration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLOS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003elength of stay\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emagnetic resonance cholangiopancreatography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eper-protocol\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSPSS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTROBE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was approved by the Hamad Medical Corporation Medical Research Center (approval number: MRC-01-25-700) and was conducted in accordance with the Declaration of Helsinki. Patient consent for anonymised data use was obtained or waived in accordance with institutional policy.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. This manuscript contains no individual person\u0026rsquo;s data in any form.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Patient data were de-identified and managed in accordance with institutional data protection policies. Public sharing of the raw dataset is not permitted due to ethical and institutional restrictions.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026rsquo; contributions\u003c/h2\u003e\n\u003cp\u003eMQA conceived the study, oversaw data collection, contributed to data analysis and interpretation, and revised the manuscript critically. AAE contributed to data collection, literature review, and drafting of the manuscript. FAI contributed to data collection and verification. AZ contributed to study design and critical revision of the manuscript. AS conceived and designed the study, led data verification and statistical analysis, drafted and revised the manuscript, and is responsible for the overall integrity of the work. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank Dr. Mohamed Said Ghali (Hamad Medical Corporation) for assistance in obtaining ethical approval from the Medical Research Center, and Dr. Shameel Musthafa (Hamad Medical Corporation) for reviewing the study results. We also acknowledge Aya Mohamed Kheir Hassan Saad, Aya Mutasim Eltayeb Abdelgadir, Ayesha Amir, Fathima Thasleem Yoosuf, and Omer Wafi for their contributions to data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLi J, Jin X, Ren J, et al. Global burden of gallbladder and biliary tract diseases: a systematic analysis for the Global Burden of Disease Study 2019. Gastroenterol Hepatol. 2022;37:1389\u0026ndash;99. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/igh.15859\u003c/span\u003e\u003cspan address=\"10.1111/igh.15859\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu PH, Yu MW, Chuang SC, et al. Comparison of laparoscopic common bile duct exploration plus cholecystectomy and endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy for elderly patients with common bile duct stones and gallbladder stones. J Gastrointest Surg. 2024;28:589\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.gassur.2024.02.026\u003c/span\u003e\u003cspan address=\"10.1016/j.gassur.2024.02.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou J, Chen Y, Yu S, et al. Comparison of one-stage and two-stage management for common bile duct stones and gallstones: a retrospective study. J Clin Gastroenterol. 2025;59:269\u0026ndash;75. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/mcg.0000000000002009\u003c/span\u003e\u003cspan address=\"10.1097/mcg.0000000000002009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTanase A, Dhanda A, Cramp M, et al. Laparoscopic common bile duct exploration: results from a prospective multi-centre UK-wide study (P-ALiCE). HPB. 2025;25:264\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.hpb.2023.07.139\u003c/span\u003e\u003cspan address=\"10.1016/j.hpb.2023.07.139\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang Z, Shao G, Li Y, et al. Efficacy and safety of laparoscopic common bile duct exploration with primary closure and intraoperative endoscopic nasobiliary drainage for choledocholithiasis combined with cholecystolithiasis. Surg Endosc. 2025;37:1700\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-022-09601-5\u003c/span\u003e\u003cspan address=\"10.1007/s00464-022-09601-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie W, Ma Z, Zuo J, et al. The efficacy and safety of laparoscopic common bile duct exploration and cholecystectomy for the treatment of difficult common bile duct stones combined with gallstones: multicenter retrospective study. Langenbecks Arch Surg. 2025;408:57\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-023-02923-3\u003c/span\u003e\u003cspan address=\"10.1007/s00423-023-02923-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang P, Song G, Xie W, et al. Comparison of one-step laparoscopy and two-step endolaparoscopy in the treatment of secondary choledocholithiasis: a multicenter retrospective clinical study. Technol Health Care. 2023;31:1333\u0026ndash;42. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3233/THC-220610\u003c/span\u003e\u003cspan address=\"10.3233/THC-220610\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRauh J, Dantes G, Wallace M, et al. Transcystic laparoscopic common bile duct exploration for pediatric patients with choledocholithiasis: a multicenter study. J Pediatr Surg. 2024;59:389\u0026ndash;92. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jpedsurg.2023.10.046\u003c/span\u003e\u003cspan address=\"10.1016/j.jpedsurg.2023.10.046\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatterson IW, Niebler JAP, Cambronero GE, et al. Spare the needle, discharge the child: trending post-operative labs after laparoscopic common bile duct exploration in pediatric patients is not helpful. Am Surg. 2024;90:56\u0026ndash;65. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/00031348241227198\u003c/span\u003e\u003cspan address=\"10.1177/00031348241227198\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVanDruff VN, Santos BF, Kuchta K, et al. The Laparoscopy in Biliary Exploration Research and Training Initiative (LIBERTI) trial: simulator-based training for laparoscopic management of choledocholithiasis. Surg Endosc. 2024;38:931\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-023-10480-5\u003c/span\u003e\u003cspan address=\"10.1007/s00464-023-10480-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310:2191\u0026ndash;4. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1001/jama.2013.281053\u003c/span\u003e\u003cspan address=\"10.1001/jama.2013.281053\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYokoe M, Hata I, Takada T, et al. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:41\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/jhbp.515\u003c/span\u003e\u003cspan address=\"10.1002/jhbp.515\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcNamee MM, Stolz MP, Harvell RT, et al. Management of choledocholithiasis in a community hospital: laparoscopic common bile duct exploration versus endoscopic retrograde cholangiopancreatography. Am Surg. 2024;90:145\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/00031348241241626\u003c/span\u003e\u003cspan address=\"10.1177/00031348241241626\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorton A, Cralley A, Brooke-Sanchez M, et al. Laparoscopic common bile duct exploration by acute care surgeons saves time and money compared to ERCP. Am J Surg. 2022;116:119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2022.03.026\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2022.03.026\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYan Y, Sha Y, Yuan W, et al. One-stage versus two-stage management for acute cholecystitis associated with common bile duct stones: a retrospective cohort study. Surg Endosc. 2022;36:920\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-021-08349-6\u003c/span\u003e\u003cspan address=\"10.1007/s00464-021-08349-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZou Q, Ding Y, Li CS, et al. A randomized controlled trial of emergency LCBDE + LC and ERCP + LC in the treatment of choledocholithiasis with acute cholangitis. Wideochir Inne Tech Maloinwazyjne. 2022;17:156\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5114/wiitm.2021.108214\u003c/span\u003e\u003cspan address=\"10.5114/wiitm.2021.108214\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu J, Zhang Y, Du P, et al. Systematic review and meta-analysis of laparoscopic common bile duct exploration in patients with previous failed endoscopic retrograde cholangiopancreatography. Surg Laparosc Endosc Percutan Tech. 2021;31:654\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SLE.0000000000000949\u003c/span\u003e\u003cspan address=\"10.1097/SLE.0000000000000949\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Ghamry EGE, El Sheikh M, Abdelhady H, et al. An auspicious experience with laparoscopic common bile duct exploration: a prospective study. Egypt J Surg. 2019;38:459\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/ejs.ejs_36_19\u003c/span\u003e\u003cspan address=\"10.4103/ejs.ejs_36_19\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Ardah MI, Barnett RE, Rotennburg H, et al. Index admission vs elective laparoscopic common bile duct exploration: a district general hospital experience over 6 years. Langenbecks Arch Surg. 2023;408:87\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00423-023-02773-z\u003c/span\u003e\u003cspan address=\"10.1007/s00423-023-02773-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePogorelić Z, Lovrić M, Jukić M, et al. The laparoscopic cholecystectomy and common bile duct exploration: single-step treatment of pediatric cholelithiasis and choledocholithiasis. Child (Basel). 2022;9:1583. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/children9101583\u003c/span\u003e\u003cspan address=\"10.3390/children9101583\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Laparoscopic common bile duct exploration, transcystic LCBDE, choledochoscope, Dormia basket, acute cholecystitis, choledocholithiasis, single-stage biliary surgery, ERCP, acute-care surgery","lastPublishedDoi":"10.21203/rs.3.rs-9468228/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9468228/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCholedocholithiasis complicating acute cholecystitis is commonly managed by staged endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Single-stage transcystic laparoscopic common bile duct exploration (LCBDE) performed concurrently with LC offers a compelling alternative. Two transcystic techniques are in routine use: choledochoscope-assisted extraction and Dormia basket-only (fluoroscopy-guided) extraction. Direct comparative data on these approaches in an acute-care emergency setting are lacking. This study aimed to compare their outcomes in patients undergoing emergency LC for acute biliary presentations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eRetrospective cohort study at Hamad General Hospital, Doha, Qatar (January 2020\u0026ndash;December 2021). After formal dataset verification (exclusion of one LC\u0026thinsp;+\u0026thinsp;IOC-only case and two duplicate entries), 154 patients undergoing attempted transcystic LCBDE were included: 41 (26.6%) in the choledochoscope group and 113 (73.4%) in the Dormia basket group. Patients were assigned to groups based on the primary instrument attempted (primary-attempt strategy). Primary outcome was intraoperative common bile duct (CBD) clearance rate. Secondary outcomes included cannulation success, postoperative ERCP requirement, complications, 30-day readmission, and length of stay. Between-group comparisons used Fisher\u0026rsquo;s exact test. Analyses were performed on both intention-to-treat (ITT) and per-protocol (PP) frameworks. The study adheres to STROBE guidelines.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBoth techniques achieved comparable outcomes across all measured endpoints. Using a primary-attempt strategy, cannulation success was 90.2% (37/41) in the choledochoscope group versus 90.3% (102/113) in the Dormia group (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Per-protocol CBD clearance was 81.1% (30/37) versus 82.4% (84/102) respectively (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Postoperative ERCP was required in 19.5% (8/41) versus 20.4% (23/113) of cases (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000). Documented complication rate based on operative log entries was 1.3% (2/154; bile leak in one patient per group). No biliary injuries, duodenal injuries, or bleeding events were documented.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn this verified cohort of 154 patients undergoing emergency transcystic LCBDE, choledochoscope-assisted and Dormia basket-only approaches showed no statistically significant difference in rates of cannulation, intraoperative CBD clearance, postoperative ERCP requirement, or complications. Single-stage LCBDE is safe and effective in acute-care settings regardless of technique. Technique selection should be guided by intraoperative anatomy, stone burden, and available equipment rather than perceived superiority of either approach. Prospective randomised studies in matched acute-care cohorts are required to refine technique-selection criteria.\u003c/p\u003e","manuscriptTitle":"Transcystic Laparoscopic Common Bile Duct Exploration (LCBDE) Combined with Laparoscopic Cholecystectomy for Acute Biliary Presentations: A Comparative Cohort Study of Choledochoscope-Assisted and Dormia Basket-Only Techniques","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-04 10:20:44","doi":"10.21203/rs.3.rs-9468228/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":"93059c76-e61f-4d2b-8fc7-a6d8b069988e","owner":[],"postedDate":"May 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T10:20:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-04 10:20:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9468228","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9468228","identity":"rs-9468228","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}