Endoscopic retrograde cholangiopancreatography versus common bile duct exploration in the treatment of choledocholithiasis: a systematic review and meta-analysis

Choledocholithiasis is commonly managed using either endoscopic retrograde cholangiopancreatography (ERCP) or common bile duct exploration (CBDE). Although both approaches are widely used their comparative efficacy, safety and cost-effectiveness remain debated in the context of contemporary laparoscopic and endoscopic practice. A systematic review and meta-analysis was performed of randomised controlled trials and observational studies comparing ERCP with open or laparoscopic CBDE for the management of choledocholithiasis. PubMed, Embase and Scopus were searched for studies published from January 2013 to 25 March 2026. The primary outcome was procedural success. Secondary outcomes included: retained or recurrent stones, overall complications, severe complications, length of stay and hospitalisation cost. Meta-analysis was performed using pooled risk ratios or mean differences with 95% confidence intervals. Thirty-three studies were included. Procedural success was comparable between CBDE and ERCP (RR 0.98, 95% CI 0.95–1.02). CBDE was associated with a significantly lower risk of retained or recurrent stones (RR 0.64, 95% CI 0.44–0.94) and fewer overall complications (RR 0.77, 95% CI 0.64–0.93). Severe complications were not significantly different between groups (RR 1.15, 95% CI 0.98–1.36). CBDE was associated with lower hospitalisation costs, while length of stay did not differ significantly. Stone size was larger in the CBDE group, although this difference was not statistically significant. CBDE provides ductal clearance comparable to ERCP while reducing retained or recurrent stones and overall complications. Severe complications were not significantly different between approaches. These findings support an individualised approach to choledocholithiasis management based on patient factors and institutional resources.