Laparoscopic Cholecystectomy after Endoscopic Bile Duct Clearance in Patients with Choledocholithiasis: A Single-Centre Cohort Study

BACKGROUND: Laparoscopic cholecystectomy after endoscopic bile duct clearance for choledocholithiasis is often performed in the setting of marked inflammatory and fibrotic changes in Calot’s triangle. Safe cholecystectomy tools and endoscopic lithotripsy techniques are usually evaluated separately, and their combined use within a single algorithm has not been sufficiently studied. AIM: To compare the rate of difficult laparoscopic cholecystectomy in patients with chronic calculous cholecystitis after endoscopic bile duct clearance for choledocholithiasis before and after the implementation of a diagnostic and treatment algorithm. METHODS: Single-centre cohort study with historical controls. Group I (January 2019 to December 2023) underwent bile duct clearance with mechanical lithotripsy without a formalised intraoperative checklist; group II (January 2024 to July 2026) was treated according to an algorithm comprising cholangioscopic thulium fibre laser lithotripsy for complex stones, formalised timing of surgery and an intraoperative safety checklist. The primary outcome was difficult cholecystectomy (at least one of: operative time 90 min, blood loss 200 mL, gallbladder perforation with bile spillage). Secondary outcomes were achievement of the critical view of safety, conversion and Clavien–Dindo grade IIIa or higher complications within 30 days. RESULTS: Of 108 patients, 56 were in group I and 52 in group II. The groups were comparable in sex, age and clinical course but differed in the timing of surgery (early cholecystectomy in 16.1% vs 69.2%; p0.001). Difficult cholecystectomy occurred in 33/56 (58.9%) vs 17/52 (32.7%) patients (odds ratio 0.34; 95% confidence interval 0.15–0.74; p=0.006). The critical view of safety was achieved in 38/56 (67.9%) vs 45/52 (86.5%) patients (p=0.022), and conversion occurred in 6/56 (10.7%) vs 1/52 (1.9%) (p=0.115). There were no bile duct injuries. Open choledochotomy was required in 4/56 (7.1%) vs 1/52 (1.9%) patients (p=0.365), and postoperative complications occurred in 4/56 (7.1%) vs 1/52 (1.9%) (p=0.365). CONCLUSION: Implementation of the algorithm in patients with chronic calculous cholecystitis and choledocholithiasis was associated with a significantly lower rate of difficult laparoscopic cholecystectomy and a higher rate of achieving the critical view of safety; differences in conversion and complication rates were not significant. The historical-control design, the imbalance in the timing of surgery and the simultaneous implementation of several components preclude assessment of the contribution of each component; prospective validation is required.