Reconsidering the “surgery-first” paradigm in choledocholithiasis: balancing innovation with global applicability

To the Editor, Choledocholithiasis remains a prevalent and clinically significant condition requiring timely biliary decompression to prevent complications such as acute cholangitis and pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP), combined with laparoscopic cholecystectomy, has long been established as the standard of care in most institutions. In a recent study published in the Journal of the American College of Surgeons, Conner et al[1] propose a paradigm shift toward a surgeon-led “surgery-first, one-stop” approach using laparoscopic common bile duct exploration (LCBDE), demonstrating improved duct clearance rates and reduced hospital length of stay. These findings reinforce accumulating evidence supporting LCBDE as an effective single-stage strategy for bile duct stone management. Contemporary meta-analyses suggest that LCBDE achieves comparable, and in some cases superior, duct clearance rates relative to ERCP, while avoiding procedure-related complications such as post-ERCP pancreatitis and enabling definitive management in a single admission[2,3]. The progressive improvement in outcomes reported by Conner et al further highlights the impact of institutional experience and technical standardization, particularly with the adoption of adjuncts such as choledochoscopy and balloon sphincteroplasty. However, the generalizability of a “surgery-first” paradigm warrants careful scrutiny. The study’s retrospective, single-center design introduces inherent selection bias, and its success is closely tied to the presence of advanced laparoscopic expertise, fluoroscopic capability, and a well-integrated acute care surgery model. Such resources are not uniformly available, particularly in low- and middle-income countries, where ERCP remains more accessible and scalable than LCBDE[4]. Furthermore, the technical learning curve associated with LCBDE is substantial and may limit its safe and widespread adoption outside high-volume centers. Patient selection remains a critical determinant of optimal outcomes. While LCBDE offers clear advantages in selected patients, complex cases, including those with large or impacted stones, altered biliary anatomy, or severe inflammation, may still benefit from staged or endoscopic approaches[5]. Current international guidelines continue to endorse both ERCP and LCBDE as acceptable strategies, emphasizing individualized, resource-sensitive decision-making rather than universal adoption of a single modality[6]. From a systems perspective, the shift toward surgeon-led management represents a meaningful evolution in care delivery. In high-resource settings, this model may streamline care, reduce delays, and improve efficiency. However, its implementation without parallel investments in training and infrastructure risks exacerbating disparities in access to safe biliary interventions. A balanced approach that integrates innovation with contextual feasibility remains essential. In light of these considerations, prospective multicenter studies are needed to validate the broader applicability of the “surgery-first” approach, define standardized training pathways, and evaluate long-term outcomes and cost-effectiveness. Until such evidence is available, the management of choledocholithiasis should remain individualized, guided by patient factors, institutional expertise, and resource availability rather than a singular procedural paradigm. This study followed the Transparency in the Reporting of Artificial Intelligence (TITAN) guidelines 2025[7].