A Comparative Study of the Results Between Choledocholithotomy and ERCP-Assisted Stone Extraction in the Treatment of Choledocholithiasis

Abstract

Choledocholithiasis is a common and clinically significant complication of gallstone disease that may lead to obstructive jaundice, cholangitis, pancreatitis, and other serious biliary complications. Although endoscopic retrograde cholangiopancreatography (ERCP) is widely regarded as the preferred first-line treatment in many settings, open choledocholithotomy remains a commonly performed procedure in resource-limited settings. Comparative local data from Pakistan remains limited. Objective: To compare the outcomes of choledocholithotomy and ERCP-assisted stone extraction in the treatment of choledocholithiasis. Methods: This prospective cohort study was conducted in the Department of General Surgery, Nishtar Medical University and Hospital, Multan, Pakistan, from 20 March 2025 to 20 July 2025. A total of 60 patients with choledocholithiasis were enrolled using non-probability, consecutive sampling and allocated to two groups: ERCP-assisted stone extraction (n=30) and choledocholithotomy (n=30). Patients aged 18–60 years of either sex with imaging-confirmed choledocholithiasis were included. Primary and secondary outcomes included stone clearance, operative time, hospital stay, postoperative pain, bile leak, surgical site infection, raised bilirubin, and overall postoperative morbidity. Data were analyzed using SPSS version 29. Continuous variables were compared using the independent-samples t-test, while categorical variables were compared using the chi-square test or Fisher’s exact test. A p-value ≤0.05 was considered statistically significant. Results: The overall mean age was 41.87 ± 10.94 years, and 58.3% of participants were male. ERCP was associated with significantly shorter operative time (46.80 ± 12.44 vs 92.57 ± 18.63 minutes, p<0.001), shorter hospital stay (2.87 ± 1.11 vs 6.73 ± 1.86 days, p<0.001), and lower pain scores on postoperative day 4 (2.13 ± 0.86 vs 4.77 ± 1.25, p<0.001) and day 8 (0.73 ± 0.52 vs 1.93 ± 0.83, p<0.001). Stone clearance was comparable between the ERCP and choledocholithotomy groups (90.0% vs 96.7%, p=0.301). Surgical site infection occurred only in the choledocholithotomy group (13.3%, p=0.038). Overall postoperative morbidity was significantly lower in the ERCP group than in the choledocholithotomy group (13.3% vs 43.3%, p=0.010). Conclusion: ERCP-assisted stone extraction achieved stone clearance comparable to choledocholithotomy while offering significantly shorter operative time, reduced hospital stay, less postoperative pain, and lower overall morbidity. Where expertise and facilities are available, ERCP may be considered the preferred treatment option for choledocholithiasis.