Evaluation of a single-stage laparoscopic cholecystectomy and laparoscopic common bile duct exploration service pre-, intra- and Post-COVID-19 pandemic: a retrospective cohort study

Background: Single-stage management of concomitant cholelithiasis and choledocholithiasis consists of performing laparoscopic common bile duct exploration (LCBDE) at the same time as laparoscopic cholecystectomy (LC). The study aimed to evaluate the delivery of our single-stage LC + LCBDE service pre-, intra- and post-COVID-19 pandemic and assess the feasibility, efficacy and safety of this complex approach. Methods: Between April 2016 and February 2024, 237 consecutive patients underwent the single-stage approach of LC + LCBDE for the management of cholelithiasis with choledocholithiasis. Patients were divided into three groups: pre-pandemic (April 2016-February 2020, n = 144), intra-pandemic (March 2020-December 2021, n = 37) and post-pandemic (January 2022-February 2024, n = 56). All patients were assessed with preoperative liver function tests (LFTs) and abdominal imaging, including ultrasound, computed tomography and/or magnetic resonance cholangiopancreatography (MRCP). Data such as demographics, investigations, intraoperative findings and postoperative outcomes were compared between the groups. Results: The median age of the 237 patients was 56 (43-71) years, and 154 (65.0%) were female patients. Clinical features at presentation included abnormal LFTs (n = 77, 32.5%), jaundice (n = 57, 24.1%), pancreatitis (n = 51, 21.5%) and common bile duct dilatation (n = 49, 20.7%). Prior to the pandemic, there was a higher percentage of ultrasound scans (88.2% vs 78.4% vs 66.1%; p = 0.068) and lower percentage of MRCPs (29.2% vs 35.1% vs 58.9%; p = 0.002) performed compared to intra- and post-pandemic, respectively. Ultrasound imaging had a markedly higher overall false negative rate for cholelithiasis with choledocholithiasis compared to MRCP imaging (59.1% vs 13.6%). There was a significant increase in the use of ultra-thin (≤3 mm) choledochoscopes following the start of the pandemic (45.1% vs 95.7%; p<0.001) and a higher number of proximal common hepatic duct views obtained (47.2% vs 64.5%; p = 0.018). There was no difference in length of stay or postoperative complications between the groups. Although the LCBDE case volume was lower following the start of the pandemic, the caseload increased thereafter and started to recover towards pre-pandemic levels of approximately 30 cases per year. Conclusions: Following the pandemic, there was a shift away from ultrasound imaging towards MRCP imaging, as well as a change in the size of choledochoscopes used. The single-stage approach of LC + LCBDE has been shown to be a safe and resilient service despite the pandemic, providing further clinical support for the implementation of the procedure in centres where the local expertise is available.