Endoscopic retrograde cholangiopancreatography versus conservative treatment for patients with symptomatic small common bile duct stones: A randomized controlled trial

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is the recommended treatment for common bile duct stones (CBDS). However, CBDS, tiny ones, can spontaneously pass through the ampulla of Vater, reducing unnecessary ERCP and its related significant complications. Objectives: This study compared endoscopic stone extraction versus conservative treatment for managing symptomatic small CBDS. Patients and methods: This randomized controlled trial included 168 patients with symptomatic CBDS (≤ 7 mm) and gallbladder stones. Of these, 85 patients underwent endoscopic stone extraction, and 83 patients underwent conservative treatment for the CBDS, followed by laparoscopic cholecystectomy and intraoperative cholangiography between June 2019 and March 2023. The primary outcome was the overall success rate, while useless procedures, morbidity, mortality, length of hospital stay, total cost, and recurrent biliary symptoms were considered secondary outcomes. Results: Our study showed that the ERCP group had a significantly higher overall success rate (96.5% vs. 22.9%, P < 0.001), fewer useless procedures (14.1% vs. 77.1%, P < 0.001), a shorter median hospital stay (5 vs. 8 days, P < 0.001), and reduced total costs (1810 vs. 2250 US$, P < 0.001). Both groups had no significant difference in morbidity or recurrent biliary symptoms (2.4% vs. 7.2%, P = 0.14). There was no mortality rate in both groups. Conclusion: Symptomatic small CBDS should be managed surgically as early as possible. Endoscopic stone extraction has a significantly high success rate, a shorter hospital stay, and a lower total cost. The conservative treatment for symptomatic small CBDS is useless and should not be practiced.