Plain language summary
Laparoscopic-endoscopic rendezvous or preoperative endoscopic sphincterotomy before removing the gallbladder for gall stones or bile duct stones
Only one out of every five to ten people who experiences colicky abdominal pain has stones in the gallbladder or the common bile duct. These biliary stones may lead to cholecystitis (inflammation of the gallbladder), cholangitis (infection of the bile duct), hepatic abscess (abscess in the liver), or acute pancreatitis (infection of the pancreas).
There are different techniques used to remove the stones; standard laparotomy (incision in the abdomen), laparoscopic surgery, and endoscopic surgery. Laparoscopic surgery, also called minimally invasive surgery, is a modern surgical technique, in which abdominal operations are performed through long, rigid instruments, inserted through small incisions (usually 0.5 to 1.2 cm) in the abdominal wall. Endoscopy is a more general term, which describes a technique that enables a physician to examine the inside of a hollow organ, by inserting an instrument, generally flexible, through natural body openings. For biliary stones, endoscopy is performed by passing a scope, with a light, through the mouth and down the digestive tract, The physician can see where the biliary tract (liver, bile duct, and pancreas) meets the duodenum (beginning of the small intestine), which makes it easier to pass a tube, through which stones can be removed. The injection of radiologic contrast medium highlights the biliary ducts and their content. This procedure is called endoscopic retrograde cholangiopancreatography (ERCP).
A laparotomy is used if laparoscopic surgery is contraindicated. Otherwise, the procedure involves two stages: first, endoscopic removal of stones from the bile duct, followed by laparoscopic cholecystectomy (removal of gallbladder). A combined endoscopic and laparoscopic procedure, called a laparoscopic-endoscopic rendezvous technique, has been associated with fewer adverse effects, less patient discomfort, and shorter hospital stay.
This review compared the benefits and harms of laparoscopic-endoscopic rendezvous versus preoperative endoscopic sphincterotomy (cutting the muscle between the bile and pancreatic ducts) procedures followed by laparoscopic cholecystectomy to remove stones from the gallbladder and bile duct. By searching scientific databases and trials registers, we found five randomised clinical trials that compared the two approaches, and involved a total of 516 participants. The majority of the participants were females and the age of both men and women ranged from 21 years to 87 years.
Only one trial stated they had not received industry sponsorship or other for-profit support. None of the other trials disclosed information about funding. Three trials stated the investigators had no competing interest; the other two trials did not provide information on competing interests.
The laparoscopic-endoscopic rendezvous approach could be associated with a lower rate of overall morbidity and clinical post-operative pancreatitis, and a shorter hospital stay. We found no clear differences in overall mortality between the two techniques. Total operative time was longer with the rendezvous approach.
We were unable to draw firm conclusions because of the lack of data. Further research is needed to confirm whether the single-stage approach is safer and more efficacious than the two-stage approach, and to address other important issues, such as quality of life and cost analysis.
Quality of the evidence
The quality of the evidence was low or very low, because of small numbers of participants, high risk of bias, and inconsistent and imprecise results across trials. The evidence is current to February 2017.