Sequential endoscopic and laparoscopic treatment for choledocholithiasis: a 30-year experience in the era of evolving techniques

Background: Sequential endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (EST) followed by laparoscopic cholecystectomy (LC) is a standard minimally invasive approach for treating concomitant gallbladder and common bile duct stones. This study presents a 30-year experience with this strategy and compares its outcomes with emerging single-session techniques, including laparoscopic common bile duct exploration (LCBDE) and laparoendoscopic rendezvous (LERV). Methods: Between October 1991 and December 2020, a total of 350 patients (mean age 65 years, range 35–80) underwent EST and/or ERCP followed by LC in a sequential treatment protocol for choledocholithiasis. Patient demographics, intra- and post-procedural variables, complication rates, and long-term outcomes were retrospectively reviewed. The success rate of stone clearance, morbidity, mortality, and recurrence rates were calculated. Results: Of the 350 treated patients, 240 (68.6%) had confirmed CBD stones. ERCP/EST achieved stone clearance in a single-session in 180 patients (75%). Among the remaining cases, additional ERCP sessions were required, and 14 patients ultimately failed to achieve endoscopic clearance. Three patients discontinued treatment (two declined a second ERCP and one refused LC after endoscopic clearance). Laparoscopic cholecystectomy was aborted in three patients (one due to anesthetic intolerance and two due to severe inflammation). Post-procedural complications occurred in 21 patients (6%), predominantly comprising mild pancreatitis and minor bile leak, or wound infections. No mortality was observed. Median hospital stay was 5.5 days. Recurrent CBD stones were observed in 15 patients (4.3%), managed with repeat ERCP (8 cases) or surgical revision (7 cases). Conclusions: While sequential therapy remains an effective and widely adopted technique, the growing body of evidence on single-session, minimally invasive strategies such as LCBDE and LERV offers valuable alternatives in selected scenarios. Each approach presents specific advantages and challenges, and the choice of treatment should be guided by individual patient characteristics, clinical context and available institutional expertise.