Single-stage versus two-stage ERCP and laparoscopic cholecystectomy for gallbladder stones with choledocholithiasis: a retrospective cohort study with long-term prognostic comparative analysis

Abstract

Introduction

The optimal treatment strategy for gallbladder stones with concurrent choledocholithiasis remains controversial. This study aims to compare the long-term prognosis of single-stage versus two-stage approaches combining endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC).

Methodology

A retrospective cohort study was conducted from January 2020 to December 2022, including 120 patients with gallbladder stones and choledocholithiasis. Patients were divided into two groups: single-stage group (n = 57) underwent the single-stage procedure (simultaneous ERCP and LC), whereas two-stage group (n = 63) received the two-stage approach (ERCP followed by LC after 2–8 weeks). Perioperative parameters, early complications, stone recurrence, cholangitis recurrence, and quality of life were assessed using Gastrointestinal Quality of Life Index (GIQLI). Survival analysis was performed using Kaplan-Meier curves and log-rank tests.

Results

Single-stage group demonstrated shorter total operative time (156.2 ± 28.5 vs. 189.7 ± 32.2 min, P < 0.001), reduced hospital stay (3.0 vs. 5.0 d, P < 0.001), and lower total medical costs (32,457 ± 4,235 vs. 38,789 ± 5,568 CNY, P < 0.001) compared to two-stage group. Both groups achieved comparable high success rates (96.5% vs. 96.8%) with similar blood loss and early complication rates (14.0% vs. 19.1%, P > 0.05). No mortality occurred in either group. During follow-up of 36 months, stone recurrence (12.3% vs. 14.3%) and cholangitis recurrence rates (8.8% vs. 11.1%) were similar between groups, with no significant differences in recurrence-free survival curves (P > 0.05). Quality of life assessment showed superior early recovery in single-stage group at one month postoperatively (GIQLI score: 85.1 ± 15.2 vs. 78.3 ± 9.8, P < 0.05), but both groups achieved equivalent long-term quality of life outcomes at 36 months follow-up (116.7 ± 12.5 vs. 115.2 ± 11.8, P > 0.05).

Conclusion

Both single-stage and two-stage approaches provide safe and effective treatment for gallbladder stones with choledocholithiasis. The single-stage strategy offers advantages in operative efficiency, hospital stay, cost-effectiveness, and early quality of life recovery, while maintaining comparable long-term recurrence rates and safety profiles.

Introduction

Choledocholithiasis refers to the presence of stones within the common bile duct (CBD), occurring in approximately 1–15% of patients with cholelithiasis [1, 2]. Without timely intervention, choledocholithiasis may lead to serious complications including cholangitis and pancreatitis [3, 4]. Secondary choledocholithiasis, resulting from gallstone migration into the CBD, represents the most prevalent form [5, 6].

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) has become the standard treatment for gallbladder stones with concurrent choledocholithiasis, as cholecystectomy effectively prevents recurrent stone migration [7, 8]. However, controversy exists regarding the optimal timing of these procedures [9, 10]. The traditional approach involves initial ERCP for CBD stone removal, followed by interval LC performed several weeks later (typically 6–8 weeks) [9]. Recently, the single-stage approach, completing ERCP immediately followed by LC under one anesthetic session, has gained increasing attention [11].

Evidence from randomized controlled trials and meta-analyses demonstrates that the single-stage approach offers advantages in operative efficiency, shorter hospital stay, reduced total anesthesia time, and cost-effectiveness, while maintaining comparable safety profiles [12–14]. A meta-analysis of eight randomized trials involving 977 patients reported that single-stage intraoperative ERCP plus LC achieved lower postoperative complication rates (1.0% vs. 4.4%) and reduced post-ERCP pancreatitis incidence compared to the two-stage approach [12]. During the COVID-19 pandemic, many institutions adopted the single-stage approach due to its effectiveness in reducing hospital admissions and resource utilization [15]. However, some studies reported higher intraoperative blood loss and bile leakage rates with the single-stage approach [16]. Despite these findings, most existing studies have focused on short-term perioperative outcomes, with limited long-term follow-up data regarding stone recurrence, cholangitis episodes, and quality of life assessments.

Therefore, this study aimed to compare single-stage and two-stage treatment approaches for patients with gallbladder stones and concurrent choledocholithiasis. The primary objective was to compare long-term outcomes including stone recurrence and cholangitis recurrence rates between the two approaches over a 36-month follow-up period. Secondary objectives included comparison of perioperative parameters (operative time, blood loss, hospital stay, and medical costs), early complication rates, and quality of life outcomes assessed. This investigation tried to provide evidence-based guidance for clinical decision-making and contribute to the establishment of standardized treatment protocols.

Methods

Study design

This study was designed as a retrospective cohort analysis conducted at a tertiary hospital from January 2020 to December 2022. Patients were categorized into two groups based on the surgical strategies they received: the single-stage group underwent simultaneous ERCP with common bile duct stone extraction followed by LC in the same anesthetic session, while the two-stage group received ERCP with stone extraction as the initial procedure, followed by laparoscopic cholecystectomy performed as a separate procedure after 2–8 weeks interval period.

Diagnosis criteria

Gallbladder stones were diagnosed using transabdominal ultrasonography demonstrating echogenic foci with posterior acoustic shadowing within the gallbladder lumen. When ultrasonographic findings were inconclusive, additional imaging modalities including computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), or endoscopic ultrasonography (EUS) were performed based on clinical availability. The diagnosis of CBD stones required the combination of biochemical abnormalities and imaging confirmation. Biochemical criteria for suspecting choledocholithiasis included elevated total bilirubin (TBIL) > 2.0 mg/dL, alkaline phosphatase (ALP) > 1.5 times upper normal limit, and gamma-glutamyl transferase (GGT) > 3 times upper normal limit. These biochemical thresholds were determined with reference to the ASGE risk stratification framework for suspected choledocholithiasis and were adapted to our institutional clinical practice [17]. The definitive diagnosis was confirmed by at least one imaging modality, MRCP, EUS, or transabdominal ultrasonography demonstrating filling defects within the CBD with associated biliary dilatation (CBD diameter > 6 mm).

Patient selection

As this was a retrospective study, sample size was determined by the number of eligible patients during the study period.

Patients were included in the study if they met the following criteria: age ≥ 18 years, imaging-confirmed diagnosis of gallbladder stones with concurrent CBD stones according to the aforementioned diagnostic criteria, treatment with ERCP followed by LC, and complete clinical records with adequate follow-up data. Patients were excluded if they presented with acute suppurative cholangitis, biliary malignancy, previous history of biliary tract surgery, or severe cardiopulmonary dysfunction that contraindicated surgical intervention.

Treatment strategies

All procedures were performed by the same experienced surgical and anesthesia teams.

In the single-stage group, patients underwent simultaneous ERCP with CBD stone extraction followed immediately by LC under the same general anesthesia session. The ERCP procedure was performed in the prone position using a side-viewing duodenoscope, involving selective cannulation of the papilla of Vater with a sphincterotome, contrast cholangiography to confirm stone location and CBD diameter, endoscopic sphincterotomy using electrocautery, and stone extraction employing retrieval balloons, Dormia baskets, or mechanical lithotripsy for larger stones. Stone clearance was confirmed by completion cholangiography and absence of filling defects. Following successful CBD clearance, patients were repositioned supine for laparoscopic cholecystectomy using the critical view of safety technique with standardized four-port placement (5 mm umbilical port for camera, 5 mm epigastric and midclavicular ports, and 5 mm anterior axillary line port), CO₂ insufflation at 12–15 mmHg, and systematic dissection of Calot’s triangle. After achieving the critical view of safety, the cystic artery and cystic duct were clipped and divided using titanium clips, followed by gallbladder dissection from the liver bed using electrocautery and placement in an extraction bag for removal through the umbilical port.

In the two-stage group, patients first underwent ERCP with CBD stone extraction using identical techniques as described above, followed by laparoscopic cholecystectomy performed as a separate procedure after an interval period ranging from 2 to 8 weeks. The LC technique remained identical to that used in the single-stage group, with complete dissection of Calot’s triangle, clear identification of the critical view of safety comprising three components (clear view of hepatocystic triangle, two and only two structures crossing into the gallbladder, and liver bed visible through the tissue), prior to clipping and division of the cystic artery and cystic duct using titanium clips.

Postoperative management was standardized for both groups, including analgesia with nonsteroidal anti-inflammatory drugs or opioids as needed, prophylactic antibiotics administered for 24–48 h, early mobilization within 6–8 h postoperatively, and gradual diet advancement from clear liquids to regular diet as tolerated. Patients were monitored for complications and discharged when clinically stable with appropriate oral medications and follow-up instructions.

Follow-up and outcome measures

All patients were followed up at predetermined intervals including 1 month, 3 months, 6 months, 12 months, 24 months, and 36 months postoperatively. Follow-up data were collected from the electronic medical record system, outpatient clinic records, and telephone interviews with patients or their families when necessary.

Perioperative data extracted from medical records included patient demographics, comorbidities, American Society of Anesthesiologists (ASA) physical status [18], baseline laboratory values obtained prior to any intervention, stone characteristics, operative time, blood loss volume, length of hospital stay, and total medical costs. Early complications occurring within 30 days postoperatively were documented, including bleeding, bile leak, wound infection, pancreatitis, perforation, and mortality. Late complications occurring beyond 30 days included bile duct stricture, recurrent cholangitis, and incisional hernia.

Long-term outcomes assessed during follow-up visits included stone recurrence, recurrent cholangitis episodes, need for repeat interventions, quality of life assessment using Gastrointestinal Quality of Life Index (GIQLI) [19], and overall survival. Stone recurrence was confirmed through MRCP, EUS, or CT imaging showing new filling defects in the biliary tree. Recurrent cholangitis was diagnosed based on clinical presentation of fever and abdominal pain combined with laboratory evidence of elevated white blood cell count, bilirubin, or liver enzymes, and imaging confirmation of biliary obstruction or dilatation.

Statistical analysis

Patients were analyzed according to the treatment strategy they actually received (as-treated analysis). All enrolled patients were included in the final analysis. All statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA) and R software version 4.3.0. Normality of continuous variables was assessed using the Shapiro-Wilk test. Continuous variables were expressed as mean ± standard deviation for normally distributed data or median with interquartile range for non-normally distributed data, and categorical variables were expressed as frequencies and percentages. Comparisons between the single-stage and two-stage groups were performed using independent t-test for normally distributed continuous variables, Mann-Whitney U test for non-normally distributed continuous variables, and chi-square test or Fisher’s exact test for categorical variables as appropriate. Survival analysis was conducted using the Kaplan-Meier method to estimate recurrence-free survival curves, with differences between groups assessed using the log-rank test. Results were presented with 95% confidence intervals (CI). For continuous variables with normal distribution, 95% CI was calculated as mean ± 1.96 × standard error. For proportions, 95% CI was calculated using the Wilson score method. For median values, 95% CI was estimated using bootstrap resampling method. A two-sided P-value < 0.05 was considered statistically significant.

Results

Baseline characteristics

As shown in Table 1, the study enrolled 120 patients with gallbladder stones and choledocholithiasis, with 57 patients in the single-stage group and 63 patients in the two-stage group. Baseline characteristics including demographics, comorbidities, ASA classification, laboratory parameters, and stone characteristics were comparable between the two groups (all P > 0.05).

Table 1.

Baseline characteristics of two groups

Characteristic	Single-stage Group (n = 57)	Two-stage Group (n = 63)	Statistic	P-value
Demographics
Age (years)	58.42 ± 12.35	61.27 ± 14.18	1.168	0.245
Female, n (%)	32 (56.14)	38 (60.32)	0.215	0.643
BMI (kg/m²)	24.78 ± 3.42	25.31 ± 3.89	0.798	0.432
Comorbidities, n (%)
Diabetes mellitus	14 (24.56)	18 (28.57)	0.246	0.620
Hypertension	22 (38.60)	27 (42.86)	0.225	0.635
CAD	8 (14.04)	12 (19.05)	0.541	0.462
COPD	5 (8.77)	7 (11.11)	0.182	0.670
Previous abdominal surgery, n (%)	11 (19.30)	15 (23.81)	0.359	0.549
ASA Classification, n (%)			0.701	0.704
I	18 (31.58)	16 (25.40)
II	28 (49.12)	32 (50.79)
III	11 (19.30)	15 (23.81)
Laboratory Parameters
WBC (×109/ L)	8.95 ± 2.34	9.12 ± 2.67	0.369	0.713
TBIL (µmol/L)	59.01 (36.25–98.81)	63.61 (40.02-104.65)	0.543	0.587
ALP (U/L)	185.5 (142.0-248.5)	192.0 (155.0-267.0)	0.712	0.477
GGT (U/L)	156.0 (98.5-234.5)	168.0 (112.0-251.0)	0.895	0.371
ALT (U/L)	89.0 (54.5-128.5)	95.0 (61.0-142.0)	0.674	0.500
AST (U/L)	78.5 (49.0-115.0)	84.0 (52.0-124.0)	0.523	0.601
Albumin (g/L)	37.82 ± 4.54	37.21 ± 5.27	0.676	0.500
Stone Characteristics
GB stone number, n (%)			0.218	0.641
Single	15 (26.32)	19 (30.16)
Multiple	42 (73.68)	44 (69.84)
GB stone size (mm)	12.45 ± 4.67	13.12 ± 5.23	0.737	0.463
CBD stone number, n (%)			0.155	0.694
Single	31 (54.39)	32 (50.79)
Multiple	26 (45.61)	31 (49.21)
CBD stone size (mm)	8.34 ± 3.12	8.78 ± 3.45	0.730	0.467
CBD diameter (mm)	9.87 ± 2.34	10.23 ± 2.67	0.782	0.436

Continuous variables: values are expressed as mean ± SD or median (interquartile range); Categorical variables: values are expressed as numbers (percentage)

Abbreviations: BMI Body mass index, CAD Coronary artery disease, COPD Chronic obstructive pulmonary disease, ASA American Society of Anesthesiologists, WBC White blood cell count, TBIL Total bilirubin, ALP Alkaline phosphatase, GGT Gamma-glutamyl transferase, ALT Alanine aminotransferase, AST Aspartate aminotransferase, GB Gallbladder, CBD Common bile duct

Perioperative outcomes and early complications

As demonstrated in Table 2, the single-stage group showed significantly shorter total operative time (156.23 ± 28.45 vs. 189.67 ± 32.18 min, P < 0.001), shorter hospital stay (3.00 vs. 5.00 days, P < 0.001), and lower total medical costs (32456.78 ± 4234.56 vs. 38789.23 ± 5567.89 CNY, P < 0.001) compared to the two-stage group. Both groups achieved comparable success rates for CBD stone clearance (96.49% vs. 96.83%) and LC completion (98.25% vs. 98.41%). Four patients with incomplete initial CBD clearance underwent successful repeat ERCP for residual stone extraction within 2 weeks and were included in the follow-up analysis.

Table 2.

Perioperative outcomes comparison between two groups

Variable	Single-stage Group (n = 57)	95% CI	Two-stage Group (n = 63)	95% CI	Statistic	P-value
Total operative time (min)	156.23 ± 28.45	148.7-163.8	189.67 ± 32.18	181.6-197.8	6.004	< 0.001
ERCP procedure time (min)	52.34 ± 12.67	49.0-55.7	48.92 ± 11.23	46.1–51.7	1.568	0.120
LC procedure time (min)	68.45 ± 15.23	64.4–72.5	72.18 ± 18.67	67.5–76.9	1.192	0.236
Blood loss (mL)	45.00 (30.00–65.00)	38.0–52.0	52.00 (35.00–75.00)	44.0–60.0	1.456	0.145
Complete CBD stone clearance, n (%)	55 (96.49)	87.9–99.6	61 (96.83)	89.0-99.6	-	1.000*
Successful LC completion, n (%)	56 (98.25)	90.6–99.9	62 (98.41)	91.5–99.9	-	1.000*
Total length of stay (days)	3.00 (2.00–4.00)	2.5–3.5	5.00 (4.00–7.00)	4.5-6.0	5.234	< 0.001
ICU stay required, n (%)	3 (5.26)	1.1–14.6	2 (3.17)	0.4–11.0	-	0.667*
Total medical cost (CNY)	32456.78 ± 4234.56	31,336–33,578	38789.23 ± 5567.89	37,388–40,190	6.956	< 0.001
Diagnostic imaging cost	398.56 ± 285.34	322.9-474.2	415.72 ± 291.46	342.3-489.1	0.328	0.744
Anesthesia cost (CNY)	2234.56 ± 534.78	2093–2376	3567.89 ± 698.45	3392–3744	11.65	< 0.001

Continuous variables: values are expressed as mean ± SD or median (interquartile range); Categorical variables: values are expressed as numbers (percentage)

Abbreviations: CBD Common bile duct, LC Laparoscopic cholecystectomy, ICU Intensive care unit, CNY Chinese yuan, ERCP Endoscopic retrograde cholangiopancreatography

*Fisher’s exact test

As shown in Table 3, overall early complication rates were comparable between groups (14.04% vs. 19.05%, P = 0.487). No mortality occurred in either group during hospitalization or within 30 days postoperatively.

Table 3.

Occurrence of early complications comparison between two groups

Indicators	Single-stage Group (n = 57)	95% CI	Two-stage Group (n = 63)	95% CI	χ²	P-value
Overall early complications, n (%)	8 (14.04)	6.3–25.8	12 (19.05)	10.3–30.9	0.484	0.487
Major Complications, n (%)
Post-ERCP pancreatitis	2 (3.51)	0.4–12.1	6 (9.52)	3.6–19.6	-	0.277
Bile leak	1 (1.75)	0.04–9.4	3 (4.76)	1.0-13.3	-	0.621*
Post-operative bleeding	1 (1.75)	0.04–9.4	2 (3.17)	0.4–11.0	-	1.000*
Perforation (duodenal/GB)	1 (1.75)	0.04–9.4	1 (1.59)	0.04–8.5	-	1.000*
Minor Complications, n (%)
Wound infection	2 (3.51)	0.4–12.1	2 (3.17)	0.4–11.0	-	1.000*
Nausea/vomiting	1 (1.75)	0.04–9.4	1 (1.59)	0.04–8.5	-	1.000*
Transient hyperamylasemia	3 (5.26)	1.1–14.6	4 (6.35)	1.8–15.5	0.057	0.811
Urinary retention	0 (0.00)	0.0-6.3	1 (1.59)	0.04–8.5	0.910	0.34
Readmission and Reoperation, n (%)
30-day readmission	2 (3.51)	0.4–12.1	4 (6.35)	1.8–15.5	0.421	0.517
Reoperation within 30 days	1 (1.75)	0.04–9.4	2 (3.17)	0.4–11.0	0.217	0.641
Mortality, n (%)
30-day mortality	0 (0.00)	0.0-6.3	0 (0.00)	0.0-5.7	-	-
In-hospital mortality	0 (0.00)	0.0-6.3	0 (0.00)	0.0-5.7	-	-

Categorical variables: values are expressed as numbers (percentage). Overall early complications represent patients experiencing any complication; patients with multiple complications were counted only once 

Abbreviations: ERCP Endoscopic retrograde cholangiopancreatography, GB Gallbladder 

*Fisher’s exact test

Long-term prognosis and quality of life comparison

During the 36-month follow-up, stone recurrence was observed in 7 cases (12.28%; 95% CI: 5.1–23.7%) in the single-stage group and 9 cases (14.29%; 95% CI: 6.8–25.4%) in the two-stage group, with no significant difference in recurrence-free survival (log-rank P = 0.7502, Fig. 1A). Cholangitis recurrence occurred in 5 cases (8.77%; 95% CI: 2.9–19.3%) in the single-stage group, and 7 cases (11.11%; 95% CI: 4.6–21.6%) in two-stage group, respectively, also without significant difference (log-rank P = 0.6770, Fig. 1B).

Fig. 1.

Long-term recurrence-free survival curves comparing single-stage and two-stage procedures. Kaplan-Meier survival curves showing recurrence-free survival rates over 36 months of follow-up. A Stone recurrence-free survival comparing single-stage (red line) and two-stage (blue line) procedures. B Cholangitis recurrence-free survival comparing single-stage (red line) and two-stage (blue line) procedures

Quality of life assessment using the GIQLI scale was shown in Fig. 2. The single-stage group demonstrated significantly higher GIQLI scores at 1 month postoperatively (85.1 ± 15.2 vs. 78.3 ± 9.8, P < 0.05), but this difference diminished from 3 months onwards. At 36-month follow-up, both groups achieved equivalent quality of life outcomes (116.7 ± 12.5 vs. 115.2 ± 11.8, P > 0.05). These findings suggest that while the single-stage approach may offer earlier quality of life recovery, both surgical strategies provide equivalent long-term quality of life outcomes for patients.

Fig. 2.

Comparison of GIQLI scores at different time points. Longitudinal comparison of GIQLI scores between single-stage (red) and two-stage (blue) groups over 36 months of follow-up. *P < 0.05 indicates statistical significance between groups at the 1-month time point. Pre-op, preoperative; 1 m, 3 m, 6 m, 12 m, 24 m, 36 m: 1, 3, 6, 12, 24, and 36 months post-operatively, respectively

Discussion

This study represented one of the few long-term comparative analyses of single-stage versus two-stage treatment approaches for gallbladder stones with choledocholithiasis, with follow-up extending to 36 months. The present investigation contributed evidence to the ongoing debate regarding optimal surgical timing by demonstrating that both approaches achieve comparable long-term efficacy profiles while revealing distinct advantages of the single-stage strategy in terms of operative efficiency, resource utilization, and early recovery parameters.

Regarding perioperative outcomes, the findings of this study demonstrated that the single-stage approach resulted in significantly shorter total operative time (156.23 vs. 189.67 min) and reduced hospital stay (3.0 vs. 5.0 days) compared with the two-stage approach. Previous studies have demonstrated that the single-stage approach achieves superior outcomes in reducing overall postoperative complication rates (1.0%) and post-pancreatitis incidence compared to the two-stage approach (4.4%) [12]. This improvement may be attributed to reduced catheter insertion attempts, avoidance of pancreatic duct manipulation, decreased contrast agent injection, and reduced risk of papillary edema. In the present study, the overall early complication rate was 14.04% in the single-stage group versus 19.05% in the two-stage group compared to the single-stage group; however, no statistically significant difference was observed between groups. Stone clearance rate serves as the primary indicator for evaluating treatment efficacy in biliary stone disease. This study demonstrated no statistically significant difference in stone clearance rates between groups (96.49% vs. 96.83%), which is consistent with multiple previous reports, confirming that different surgical timing approaches yield comparable treatment outcomes for cholelithiasis with choledocholithiasis [20, 21].

This study also revealed significantly shorter total hospital stay in the single-stage group compared to the two-stage group (3.0 vs. 5.0 days), consistent with previous investigations [22, 23]. A recent meta-analysis reported that the single-stage intraoperative ERCP combined with LC approach was associated with a mean difference of − 4.05 days (95% CI: −5.20 to − 2.90) in hospital stay compared with the two-stage approach [21]. This reduction may be attributed to the single-stage approach eliminating the waiting period between staged procedures, reducing additional hospital days associated with separate admissions, and decreasing the risk of prolonged hospitalization due to ERCP-related complications during the observation period. Notably, total operative time was shorter in the single-stage group in our study. However, another study suggested that combined ERCP and LC procedures involve more complex surgical manipulations, potentially prolonging operative time [24]. This discrepancy may be related to surgeon experience and the proficiency of surgical team collaboration. The total medical cost analysis showed that the single-stage group incurred lower expenses (32,457 vs. 38,789 CNY), representing an approximately 16% cost reduction. This finding aligns with Ramser et al. [25] who reported that single-stage laparoscopic common bile duct exploration was associated with significantly lower hospital charges ($46,685 vs. $60,537) compared with the two-stage ERCP followed by LC approach.

Concerning long-term outcomes, endoscopic sphincterotomy may compromise the physiological barrier provided by the sphincter of Oddi, leading to reflux of intestinal contents and microbial flora into the common bile duct, predisposing to recurrent primary choledocholithiasis formation, which reported with 8.9% incidence rate of primary choledocholithiasis following sphincterotomy [26]. Prior research has identified age, lipid metabolism, nutrition, obesity, biliary infection, cholestasis, biliary inflammation, periampullary diverticula, stone number and size, common bile duct diameter, and history of previous cholecystectomy or ERCP as influencing factors for stone recurrence [27]. A recent review reported that the rate of CBD stone recurrence after ERCP ranges from 4% to 30%, with an average of approximately 10–15% [28]. The results demonstrated stone recurrence rates of 12.28% versus 14.29% in both groups after 3-year follow-up, which fall within this reported range, with no statistically significant difference between groups. Cholangitis recurrence rates were also comparable between groups. Regarding quality-of-life comparisons, the single-stage group showed superior GIQLI scores compared to the two-stage group only at one month postoperatively, with no significant differences observed in subsequent follow-up assessments. At 36 months, both groups achieved equivalent quality of life outcomes. This may be related to single-stage patients avoiding the psychological burden and physical trauma of secondary surgery, providing distinct psychological advantages during early postoperative recovery, while the impact of both surgical approaches on long-term quality of life tends to converge over time.

Beyond the single-stage and two-stage ERCP combined with LC approaches evaluated in this study, laparoscopic common bile duct exploration (LCBDE) represents another established treatment modality. LCBDE offers the advantage of preserving sphincter of Oddi function by avoiding endoscopic sphincterotomy, which theoretically may reduce long-term stone recurrence risk associated with duodenobiliary reflux [29, 30]. Previous meta-analysis demonstrated that LCBDE plus LC achieved comparable stone clearance rates (OR = 2.20) and operation time compared with ERCP followed by LC, while LCBDE was associated with lower rates of post-procedural pancreatitis and cholangitis but higher rates of bile leakage [31]. Wu et al. [32] reported that in elderly patients aged ≥ 70 years, LCBDE plus LC and ERCP followed by LC showed similar stone clearance rates (92.35% vs. 95.00%) and long-term recurrence rates (13.0% vs. 12.5%). The choice between these approaches should be individualized based on institutional expertise, equipment availability, stone characteristics, and patient factors. Our institution primarily adopted the ERCP-based approach due to established endoscopic expertise and the relatively high technical demands of LCBDE.

This study still possessed several limitations. The retrospective design introduces inherent selection bias, as treatment allocation was not randomized and may have been influenced by surgeon preference, patient characteristics, or institutional protocols not captured in the analysis. As a single-center study with a relatively small sample size, the generalizability of our findings may be limited and statistical power to detect differences in less frequent outcomes was restricted. The absence of standardized criteria for treatment selection between single-stage and two-stage approaches represents another potential source of bias. The diagnostic criteria required both biochemical abnormalities and imaging confirmation, which may have excluded some patients and limited external validity. The diagnostic workup reflected real-world clinical practice rather than a standardized guideline, with various imaging modalities utilized based on clinical availability, potentially introducing bias in cost analysis. Additionally, the inability to evaluate subclinical cholangitis due to lack of established diagnostic criteria may have affected the assessment of surgical timing decisions. Future research should focus on multicenter randomized controlled trials with longer follow-up periods and standardized diagnostic protocols to validate these findings. Comparisons among single-stage ERCP plus LC, two-stage ERCP followed by LC, and LCBDE plus LC would provide valuable evidence for clinical decision-making. Additionally, cost-effectiveness analyses incorporating quality-adjusted life years would provide more detailed economic assessments.

Conclusion

This study demonstrated that both single-stage and two-stage approaches provide safe and effective treatment options for patients with gallbladder stones and choledocholithiasis. The single-stage strategy was associated with shorter operative times, reduced hospital stays, lower costs, and improved early quality of life recovery, while maintaining comparable long-term recurrence rates and safety profiles. These findings suggested that the single-stage approach may offer advantages in terms of resource utilization and patient convenience without compromising long-term clinical outcomes.

Abbreviations

ERCP

Endoscopic Retrograde Cholangiopancreatography

LC

Laparoscopic Cholecystectomy

CBD

Common Bile Duct

GIQLI

Gastrointestinal Quality of Life Index

CT

Computed Tomography

TBIL

Total Bilirubin

ALP

Alkaline Phosphatase

GGT

Gamma-Glutamyl Transferase

MRCP

Magnetic Resonance Cholangiopancreatography

EUS

Endoscopic Ultrasonography

ASA

American Society of Anesthesiologists

SPSS

Statistical Package for the Social Sciences

COPD

Chronic Obstructive Pulmonary Disease

WBC

White Blood Cell count

ALT

Alanine Aminotransferase

AST

Aspartate Aminotransferase

GB

Gallbladder

LOS

Length Of Stay

ICU

Intensive Care Unit

PEP

Post-ERCP Pancreatitis

Authors’ contributions

Yanmei Li: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original draft preparation. Shengli Ge: Data curation, Validation, Writing - Review & Editing. Changbin Peng: Resources, Project administration. Yanwei Che: Supervision, Writing - Review & Editing. All authors have reviewed and approved the final manuscript.

Funding

This study did not receive any funding.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the Institutional Review Board and Ethics Committee of Hulunbuir sino-monglian hospital (Approval number: 2025SZM-LW03). The study was conducted in accordance with the Declaration of Helsinki and reported following the Strengthening the Reporting of Cohort, Cross-sectional, and Case-control Studies in Surgery (STROCSS) 2024 guidelines. Given the retrospective nature of the study, the requirement for informed consent was waived by the Ethics Committee.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.