Minimally invasive surgical strategies for gallbladder stones with concomitant common bile duct stones: a systematic review and network meta-analysis.

Abstract

Background: Approximately 10-20% of patients with gallstones present with concomitant common bile duct stones (CBDS). Although T-tube drainage (TTD) has traditionally been used after bile duct exploration, clinical practice is increasingly shifting toward T-tube-free minimally invasive strategies to enhance postoperative recovery. This study evaluated the effectiveness and safety of these approaches using a network meta-analysis (NMA).

Methods: PubMed, Web of Science, Embase, and the Cochrane Library were searched from inception to October 2025. Randomized controlled trials (RCTs) and cohort studies were analyzed in parallel using separate frequentist NMAs. Interventions included laparoscopic cholecystectomy (LC) + laparoscopic common bile duct exploration (LCBDE) + TTD, LC + LCBDE + primary suture (PS), LC + laparoscopic transcystic common bile duct exploration (LTCBDE), and LC + endoscopic retrograde cholangiopancreatography (ERCP) performed as either a single-stage or two-stage strategy. Treatment effects were expressed as risk ratios (RRs), odds ratios (ORs), and mean differences (MDs), with treatment rankings estimated using the surface under the cumulative ranking curve (SUCRA).

Results: Fifty-two studies including 11,327 patients (19 RCTs and 33 cohort studies) were included. Parallel analyses demonstrated generally consistent findings between randomized and observational evidence. In the RCT network, T-tube-free strategies achieved comparable stone clearance and overall safety compared with TTD. LC + LTCBDE showed the highest SUCRA ranking probabilities for operative time (MD - 47.01 min; SUCRA 96.4%) and length of hospital stay (MD - 5.78 days; SUCRA 86.9%). LC + LCBDE + PS was also associated with shorter operative time (MD - 20.02 min; SUCRA 51.8%) and shorter length of hospital stay (MD - 3.03 days; SUCRA 33.8%). Long-term outcomes and postoperative complication rates were generally comparable across strategies. Differences in SUCRA ranking probabilities were observed for postoperative pancreatitis-related outcomes, with LC + ERCP (two-stage) showing a lower ranking probability (SUCRA 15.8%).

Conclusions: T-tube-free minimally invasive strategies achieved stone clearance and overall perioperative safety broadly comparable to those of TTD in patients with gallbladder stones and concomitant common bile duct stones. LC + LTCBDE and LC + LCBDE + PS were associated with shorter operative time and hospital stay in some network comparisons. Overall, treatment selection should remain individualized according to biliary anatomy, stone burden, patient condition, and institutional expertise.