European Journal of Cardiovascular Medicine

Choledocholithiasis, the presence of gallstones within the common bile duct (CBD), is a frequently encountered condition in clinical gastroenterology and hepatobiliary surgery. It is often associated with symptoms such as biliary colic, jaundice, cholangitis, and pancreatitis, warranting prompt and effective management (1,2). The current standard of care for such patients includes endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction, followed by cholecystectomy to prevent recurrence and further complications (3).

Laparoscopic cholecystectomy (LC) is the gold standard surgical procedure for gallbladder removal due to its minimally invasive nature, reduced postoperative pain, and shorter hospital stay compared to open techniques (4). However, the ideal timing of LC after successful ERCP remains debated. While some studies advocate for early cholecystectomy—performed within 72 hours—due to reduced inflammation and improved operative outcomes (5,6), others suggest delaying surgery to allow resolution of edema and inflammation around the biliary tree (7). Delayed surgery, however, is associated with potential risks such as recurrence of biliary events, readmissions, and increased morbidity in the waiting period (8).

Early LC may offer advantages in terms of operative feasibility, reduced conversion rates to open cholecystectomy, and fewer postoperative complications. Conversely, concerns about technical difficulty due to residual inflammation following ERCP have led many surgeons to delay the procedure. Existing literature presents inconsistent conclusions regarding these approaches, and there is a lack of high-quality, prospective multicenter studies comparing both strategies under standardized settings (9,10).

This prospective multicenter study aims to assess and compare the clinical outcomes, operative challenges, and complication rates between early versus delayed laparoscopic cholecystectomy after ERCP in patients diagnosed with choledocholithiasis. The goal is to provide evidence-based guidance on the optimal timing of surgical intervention following endoscopic clearance of CBD stones.

A total of 200 adult patients diagnosed with choledocholithiasis and who underwent successful endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of common bile duct (CBD) stones were included. Inclusion criteria were: age between 18 and 75 years, confirmed diagnosis of choledocholithiasis based on imaging and ERCP findings, and suitability for laparoscopic cholecystectomy. Patients with incomplete duct clearance, suspicion of malignancy, severe cardiopulmonary comorbidities, or those requiring open cholecystectomy from the outset were excluded.

Group Allocation
Eligible patients were consecutively enrolled and allocated into two groups based on timing of cholecystectomy:

• Group A (Early LC): Underwent laparoscopic cholecystectomy within 72 hours of ERCP
• Group B (Delayed LC): Underwent laparoscopic cholecystectomy 6–8 weeks after ERCP

The timing decision was based on operating room availability and surgeon discretion, with efforts to minimize bias by ensuring comparable baseline characteristics.

Surgical Procedure
All laparoscopic cholecystectomies were performed by experienced hepatobiliary surgeons using a standardized four-port technique. Intraoperative data including operative time, conversion to open surgery, and surgical difficulty (graded subjectively as mild, moderate, or severe) were recorded. A closed suction drain was placed at the surgeon’s discretion.

Data Collection
Patient demographics, baseline laboratory results, and clinical findings were documented. Primary outcomes included operative time, rate of conversion to open cholecystectomy, intraoperative and postoperative complications (e.g., bile duct injury, hemorrhage, wound infection), and length of hospital stay. Pain intensity was evaluated using the Visual Analogue Scale (VAS) at 24 hours postoperatively. Biliary events (e.g., recurrent colic, cholangitis, pancreatitis) occurring before cholecystectomy were also recorded.

Follow-Up
Patients were monitored in the immediate postoperative period and followed up at 1- and 4-weeks post-discharge for any delayed complications. Data were compiled using standardized case report forms.

Statistical Analysis
Statistical analysis was conducted using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the student’s t-test. Categorical variables were analyzed using Chi-square or Fisher’s exact test as appropriate. A p-value less than 0.05 was considered statistically significant.

A total of 200 patients were enrolled in the study, with 100 patients in each group. Baseline characteristics including age, gender distribution, and comorbidities such as diabetes and hypertension were comparable between the two groups (Table 1).

The mean operative time was significantly lower in the early LC group (68.4 ± 12.7 minutes) compared to the delayed group (82.1 ± 15.9 minutes, p < 0.001). Conversion to open surgery occurred in 5% of patients in Group A and 13% in Group B, showing a statistically significant difference (p = 0.04). Surgical difficulty was rated as severe in 8% of early cases versus 20% in the delayed group (Table 2).

Postoperative pain assessed using the Visual Analogue Scale (VAS) at 24 hours showed a lower mean score in Group A (3.2 ± 1.1) compared to Group B (4.7 ± 1.4, p < 0.01). The incidence of postoperative complications such as bile leak, wound infection, and fever was higher in the delayed group (Table 3).

Length of hospital stay was significantly shorter in the early LC group (4.1 ± 1.3 days) compared to the delayed group (6.6 ± 2.0 days, p < 0.001). Recurrence of biliary events during the waiting period was observed in 11 patients (11%) in Group B, while none were reported in Group A (Table 4).

Follow-up at 4 weeks postoperatively revealed no significant difference in late complications between the groups. Overall patient satisfaction, assessed through a post-discharge feedback form, was higher in the early intervention group (Table 5).

Table 1: Baseline Characteristics of Study Participants

Table 2: Intraoperative Parameters

Table 3: Postoperative Outcomes

Table 4: Hospital Stay and Biliary Events

Table 5: Follow-Up and Patient Satisfaction

This prospective multicenter study demonstrates that early laparoscopic cholecystectomy (LC) within 72 hours after endoscopic retrograde cholangiopancreatography (ERCP) provides superior outcomes compared to delayed surgery performed after 6–8 weeks. Specifically, early LC was associated with reduced operative time, fewer conversions to open surgery, shorter hospital stay, and a lower incidence of recurrent biliary events during the waiting period.

The timing of cholecystectomy following ERCP in patients with choledocholithiasis has long been debated. Several studies support the safety and efficacy of early cholecystectomy, highlighting its role in reducing perioperative complications and readmissions due to recurrent biliary symptoms (1,2). Our findings align with these observations, as no recurrent biliary events were reported in the early group, compared to an 11% recurrence rate in the delayed group.

Shorter operative time in the early group may be attributed to less dense adhesions and fibrosis when surgery is performed soon after ERCP, before inflammatory changes progress (3,4). Similar trends have been reported in previous studies, which noted reduced surgical difficulty and operative duration in early cholecystectomy cohorts (5,6). Moreover, conversion to open surgery, which often reflects intraoperative complexity, was significantly lower in the early group in our study. This observation is consistent with meta-analyses that have demonstrated higher open conversion rates in delayed cases due to chronic inflammation and fibrosis around the gallbladder and Calot’s triangle (7,8).

Pain control and postoperative recovery were also more favorable in the early LC group. Lower visual analogue scale (VAS) scores at 24 hours suggest that early intervention may result in less tissue handling and inflammation, leading to better postoperative outcomes (9). Additionally, early surgery significantly shortened the overall hospital stay, which has economic and logistic benefits for both patients and healthcare systems (10).

Another critical aspect is the risk of biliary events between ERCP and delayed cholecystectomy. In our study, 11% of patients in the delayed group experienced recurrent symptoms, including biliary colic and cholangitis. These findings support previous research showing that delayed surgery after ERCP increases the risk of interval complications, leading to emergency admissions and potentially more complex surgeries (11,12).

Patient satisfaction, although often underreported, is a vital component of surgical success. The higher satisfaction scores observed in the early group may reflect not only clinical outcomes but also patient preference for fewer hospital visits and faster resolution of symptoms (13). These findings are in line with earlier trials emphasizing the psychosocial and quality-of-life benefits of early surgical resolution (14).

Despite the advantages of early LC, some practitioners still prefer delayed surgery to allow recovery from ERCP-related edema and inflammation. However, our results and growing literature suggest that these concerns may be overstated and that experienced surgeons can safely perform early cholecystectomy with low complication rates (15).

Overall, our study adds to the accumulating evidence favoring early LC after ERCP in choledocholithiasis. The consistency of findings across multiple centers and standardized surgical protocols strengthens the reliability of our conclusions.

Early laparoscopic cholecystectomy following successful ERCP in patients with choledocholithiasis offers significant advantages over delayed surgery, including shorter operative time, fewer complications, reduced hospital stay, and lower risk of recurrent biliary events. These findings support early surgical intervention as a safe and more effective strategy for optimal patient outcomes.

1. Goel A, Kothari S, Bansal R. Comparative analysis of early versus late laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreaticography in cases of cholelithiasis with choledocholithiasis. Euroasian J Hepatogastroenterol. 2021;11(1):11–3. doi:10.5005/jp-journals-10018-1338. PMID: 34316458
2. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;2013(12):CD003327. doi: 10.1002/14651858.CD003327.pub4. PMID: 24338858
3. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(9):CD003327. doi: 10.1002/14651858.CD003327.pub3. PMID: 23999986
4. Cinar H, Ozbalci GS, Tarim IA, Karabulut K, Kesicioglu T, Polat AK, et al. Factors affecting the conversion to open surgery during laparoscopic cholecystectomy in patients with cholelithiasis undergoing ERCP due to choledocholithiasis. Ann Ital Chir. 2017; 88:229–36. PMID: 28874623
5. Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 2009;7(4):338–46. doi: 10.1016/j.ijsu.2009.05.005. PMID: 19481184
6. Salman B, Yilmaz U, Kerem M, Bedirli A, Sare M, Sakrak O, et al. The timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreaticography in cholelithiasis coexisting with choledocholithiasis. J Hepatobiliary Pancreat Surg. 2009;16(6):832–6. doi:10.1007/s00534-009-0169-4. PMID: 19701600
7. Şenocak R, Çelik SU, Kaymak Ş, Hançerlioğullari O. Perioperative outcomes of the patients treated using laparoscopic cholecystectomy after emergent endoscopic retrograde cholangiopancreatography for bile duct stones: does timing matter? Ulus Travma Acil Cerrahi Derg. 2020;26(3):396–404. doi:10.14744/tjtes.2020.94401. PMID: 32436986
8. Enochsson L, Lindberg B, Swahn F, Arnelo U. Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience. Surg Endosc. 2004;18(3):367–71. doi:10.1007/s00464-003-9021-0. PMID: 14752630
9. Lyu Y, Cheng Y, Li T, Cheng B, Jin X. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc. 2019;33(10):3275–86. doi:10.1007/s00464-018-06613-w. PMID: 30511313
10. Muhammedoğlu B, Kale IT. Comparison of the safety and efficacy of single-stage endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy versus two-stage ERCP followed by laparoscopic cholecystectomy six-to-eight weeks later: a randomized controlled trial. Int J Surg. 2020; 76:37–44. doi: 10.1016/j.ijsu.2020.02.021. PMID: 32105889
11. Di Mauro D, Ricciardi E, Siragusa L, Manzelli A. Outcome of laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: a comparative study. J Laparoendosc Adv Surg Tech A. 2019;29(11):1391–6. doi:10.1089/lap.2019.0383. PMID: 31355693
12. Ng T, Amaral JF. Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis. J Laparoendosc Adv Surg Tech A. 1999 Feb;9(1):31-7. doi: 10.1089/lap.1999.9.31. PMID: 10194690.
13. Al-Salem AH, Issa H. Laparoscopic cholecystectomy in children with sickle cell anemia and the role of ERCP. Surg Laparosc Endosc Percutan Tech. 2012;22(2):139–42. doi: 10.1097/SLE.0b013e3182471b1c. PMID: 22487628
14. Sahoo MR, Kumar AT, Patnaik A. Randomised study on single-stage laparo-endoscopic rendezvous (intra-operative ERCP) procedure versus two-stage approach (pre-operative ERCP followed by laparoscopic cholecystectomy) for the management of cholelithiasis with choledocholithiasis. J Minim Access Surg. 2014;10(3):139–43. doi:10.4103/0972-9941.134877. PMID: 25013330
15. Abdalkoddus M, Franklyn J, Ibrahim R, Yao L, Zainudin N, Aroori S. Delayed cholecystectomy following endoscopic retrograde cholangiopancreatography is not associated with worse surgical outcomes. Surg Endosc. 2022;36(5):2987–93. doi:10.1007/s00464-021-08593-w. PMID: 34231064