الفهرس 
ACNOWLEDGEMENTOnly 14 pages are availabe for public view
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Abstract
Standard treatment for patients with concomitant gallstones and common bile ducts stones in the pre-endoscopy era was open cholecystectomy and common bile duct exploration. With the advent of endoscopic and laparoscopic techniques, the common bile duct stones were removed preoperatively by endoscopy, which was followed by laparoscopic cholecystectomy. With refinements in laparoscopic techniques and experience many centers started doing complex laparoscopic procedures, and laparoscopic common bile duct exploration was introduced into the armamentarium of surgeons. Single-stage management of concomitant CBD and gallbladder stones is gaining popularity with increasing experience of surgeons with advanced laparoscopic procedures. It avoids the morbidity and mortality associated with ERCP as well as the need for multiple procedures. Although multiple studies have compared the single-stage with the two-stage approaches, no general has been defined regarding the optimum management of patients with cholelithiasis and choledocholithiasis. Also, there is a clear lack of Egyptian studies handling the same previous comparison That is why we conducted the current study aiming to determine the best technique for the management of patients with concomitant gallstones and common bile duct stones by comparing the success rate, complication rates. This study included 64 patients diagnosed with concomitant cholelithiasis and choledocholithiasis. They were randomly assigned into two groups; group A included 32 patients who underwent single stage approach (LC and LCBDE), while group B included the remaining 32 patients who underwent two-stage approach (preoperative ERCP followed by LC). Hospitals, Assiut, Egypt and hepatobiliary surgery unit at El Rsghi liver
All patients were subjected to complete history taking, clinical examination, and routine preoperative laboratory and radiological investigations. Clinical success was the primary outcome, while secondary ones included operative time, hospitalization period, and postoperative morbidity rate. This study was done at General Surgery Department, Assiut University hospital . he study was conducted over a two-year duration, from January 2021 till T December 2022. This study revealed the following findings: The mean age of the included cases was 41.56 and 41.59 years in Groups A and B respectively, with no significant difference between the two groups. Most of the study participants were women, as they formed 71.88% and 78.13% of cases in the same two groups respectively. The mean values of their BMI were 32.8 and 33.6 kg/m2 in the same groups respectively, which was comparable between the two study groups. The prevalence of medical comorbidities including diabetes and hypertension did not significantly differ between the two groups. The duration of patients’ symptoms had median values of 5 and 6 weeks in Groups A and B respectively, with no significant difference between the two groups. All patients reported right hypochondrial pain, while jaundice was present in 62.5% and 68.76% of cases in the same groups respectively. Other manifestations included pruritis, vomiting, and fever. All preoperative laboratory parameters showed no significant difference between the two study groups. The majority of the included cases had multiple gallstones (93.75% and 96.87% of cases in Groups A and B respectively), while most patients had single CBD stone (78.13% and 90.63% of cases in the two groups respectively). By MRCP, CBD had mean diameters of 15.33 and 15.53 mm in the same groups respectively, with no significant difference between the two groups. The time interval to cholecystectomy ranged between one and five days (median = 4 days) in group B. There was a significant prolongation in the operative time in group A compared to the other group (173.13 vs. 75.97 minutes respectively). Success was encountered in 100% and 90.62% of cases in Groups A and B respectively, with no significant difference in statistical analysis (p = 0.07). No conversion to the open approach was noted in either group. The duration of hospitalization showed a significant increase in group B (7 – 5 days in group A). Bile leakage showed a significant increase in group A (12.5% vs. 0% in the other group). Surgical site infection occurred in one case in each group (3.13%).There was a significant increase in the incidence of pancreatitis in group B (12.5% vs. 0% in group A). Based on the results of this study, it could be included that: Although success rate was higher in the single stage group (LC + LCBDE) compared to the two-stage approach, no statistical difference was detected between the two groups. Nonetheless, we still prefer the former approach because it is associated with a shorter hospital stay and better clearance rate. More studies including more cases from different hepatobiliary centers centers should be conducted in the future. As most findings were comparable between the two groups, the surgeon is recommended to choose which technique he is more experienced with and more aware of its complications.