Finally, the indications for a surgical drainage procedure or an EST must be considered. A Roux-en-Y hepaticojejunostomy, a choledochojejunostomy, or a surgical sphincteroplasty may be indicated for sphincter of Oddi stenosis/dysfunction, primary CBD stones, patients with duodenal diverticula, multiple CBD stones, or intrahepatic stones. Similarly, EST is indicated for patients with CBD stones with severe preoperative cholangitis or pancreatitis, and for sphincter of Oddi stenosis/dysfunction. When these indications overlap, open CBDE and EST are often complementary. However, open CBDE remains the “gold standard” for selected, rare patients such as those with Mirizzi syndrome, Billroth II anatomy, and those requiring a drainage procedure .
Greca et al.  reviewed the simultaneous laparoendoscopic rendezvous(RV) for the treatment of CBD stones with single stage totally laparoscopic (TL) treatment and sequential treatments (ST). Data was collected from 27 papers concerning 795 patients. The overall effectiveness of RV was 92.3 %. The morbidity rate was 5.1 %, and the mortality rate was 0.37 %. Almost all the authors were satisfied with the procedure. The authors’ comparison to ST and TL showed that the advantages outweigh the disadvantages mostly related to logistical problems. They were of the view that the results are at least comparable with those of the other available approaches. The effectiveness of RV is greater with reciprocal implementation of surgical and endoscopic procedures. The morbidity and the risk of iatrogenic damage seem lower than with ERCP-ES and the risk of residual stones lower than with TL treatment. The RV procedure is safe and can sometimes be the preferable option, but collaboration between surgeon and endoscopist is mandatory.
EST post cholecystectomy
When CBD stones are discovered intraoperatively, a surgeon has to decide whether to go ahead with single stage laparoscopic management or complete the cholecystectomy followed by sequential endoscopic clearance of CBD. Two prospective randomized studies have evaluated the merits of immediate versus delayed treatment for bile duct stones. Rhodes et al.  randomized 80 patients at the time of diagnosis by cholangiography to either laparoscopic exploration or delayed postoperative EST. Patients were excluded if they had preoperative EST, cholangitis, or acute pancreatitis. The laparoscopic approach entailed transcystic exploration (n = 28) of the duct followed, if necessary, by laparoscopic choledochotomy (n = 12) in those patients with CBD exceeding 6 mm in diameter. This study showed that both techniques were associated with a 75 % successful bile duct clearance rate at the time of first intervention. Final duct clearance was not significantly different, although there was a trend towards better clearance with the laparoscopic approach. The length of hospital stay was significantly shorter with the singlestage approach (1 day, 3.5 day; p < 0.001). There was no significant difference in morbidity (18 %, 15 %; p = NS) or mortality (0 %, 0 %). However, the authors concluded that the transcystic approach was preferred.
Stones Discovered Postoperatively
Karaliotas C. et al.  performed transcholedochal laparoscopic CBD exploration on 32 patients who had unsuccessful attempts at endoscopic CBD stone extraction. Previous operations, cholangitis, anatomic abnormalities, and stone impaction were the principal reasons for failure of ERCP. Stone extraction under direct laparoscopic choledochotomy was achieved in 20 of 31 patients (64.51 %). Biliary stents were inserted in 7 patients (21.8 %) and T tubes were placed in 21 patients (65.6 %). Five laparoscopic choledochoduodenostomies were performed. There were 11 conversions to open surgery. Morbidity was 12.5 %. The authors believed that patients with previous operations in the upper abdomen, because of adhesions, excessive fibrosis in the hepatoduodenal ligament, and altered anatomy (from Billroth II or Roux-en-Y reconstruction) and pathologic entities (Mirizzi syndrome and intrahepatic lithiasis of the left biliary tree) had the greatest relative risk of conversion to an open procedure. Stone impaction was not a predictor of method failure (odds ratio = 0.44), while it has been regarded as the number one factor of failed CBD clearance in ERCP. Laparoscopic CBD exploration after failed endoscopic stone removal was shown to be very effective (successful duct clearance was 64.51 %) despite the predicted high degree of difficulty for this patient population.
In elderly and unfit patients, ERCP and stone extraction from the CBD is the initial and probably the definitive treatment. It is also the initial treatment in patients presenting with jaundice, cholangitis or severe pancreatitis. Laparoscopic cholecystectomy is undertaken once the condition of the patient has improved. Biliary stenting is advocated for patients with large dilated CBD, multiple impacted stones or stones not completely removed by CBD .
Combined laparoscopic cholecystectomy and CBD exploration (LCBDE)
Which Approach to Use and When?
The incidence of gallstones is very common and varies from 6 % to 10 % in adult population. Their treatment involves surgeons, endoscopists and anaesthesiologists depending on clinical presentation. The “gold standard” treatment for cholecystolithiasis is laparoscopic cholecystectomy (LC), whereas the “gold standard” treatment for isolated common bile duct (CBD) stones, especially in cholecystectomized patients, is endoscopic clearance . On the contrary, when gallstones and CBD stones are present concurrently, the treatment is a challenge. A consensus on optimal management does not exist. Several approaches are used, all having their proponents, such as open surgery, laparoscopy, and laparoendoscopic treatments, either sequential or simultaneous.
Ahmed et al.  compared preoperative versus intraoperative endoscopic sphincterotomy for management of CBD stones. 198 patients diagnosed preoperatively with gallbladder and CBD stones were eligible. They were randomly divided into two groups: Preoperative endoscopic Sphincterotomy (PEST)/LC group (n = 100) and LC/Intraoperative endoscopic Sphincterotomy (IOEST) group (n = 98). The operative duration, surgical success rate, number of stone extracted, postoperative complications, retained common bile duct stones, and postoperative lengths of stay were compared prospectively. There were no statistically significant differences in surgical time, surgical success rate, CBD diameter, stone size, or stone number between the two groups. The success rate was 95.3 % and 97.8 % for PEST/LC and LC/IOEST, respectively. There were no significant difference in postoperative retained stones, surgical time, and complications, but the total hospital stay was significantly shorter in the LC/IOEST group. They concluded that PEST/LC and LC/IOEST are both good options for dealing with preoperatively diagnosed CBDS, but when there is enough experience and facilities, LC/IOEST, as a single-stage treatment, should be preferable.
In our study, after LCD, the T-tube was associated with a higher complication rate in comparison to primary closure (18.2% vs 11.1%). Also, Herrero et al., 2013 , Khaled et al., 2013 , Zhang et al., 2015 , Leida et al., 2008 , and Wu et al., 2012  noticed similar findings. However, we found less biliary complication rate on comparing primary closure with T-tube after LCD (11.1% vs 18.2% respectively), similarly, Leida et al., 2008  found less biliary complication in the primary closure group, also, Wu et al., 2012  found less biliary complication without a combination of retained stone in the primary closure group, and Podda et al., 2016  found that primary closure was associated with less biliary peritonitis.
a: OCBD extraction of stent and stone. b: Open primary closure of CBD.
In LCBDE group (21 patients): They were classified as 6(28.6%) males, and 15 (71.4%) females; their mean age was 34.05 ± 6.1 years. Three (14.3%), 15(71.4%), and 3(14.3%) of patients had their stones in CHD, mid-CBD, and distal CBD respectively. The mean CBD diameter was 14 ± 4.7 mm, furthermore, the stones were classified into large (1.5–2 cm) and very large (>2 cm) in 18(85.7%) and 3(14.3%) of patients respectively. Nineteen (90.5%), and 2(9.5%) of patients had single, and multiple stones respectively. Stones were 1ry in 1 patient and 2ry in 20 ones. The preoperative ASA score was graded as I, II, and III in 14 (66.7%), 6 (28.6%), and 1(4.8%) of patients respectively. IOC and choledochoscopy were done for all patients. After stone extraction; Primary repair of CBD, T- tube insertion, and HJ were done in 9(42.9%), 11(52.4%), and 1 (4.8%) of them respectively. Operative bleeding affected 1 of patients. The mean operative times and hospital stays were 231.4 ± 49.3 min, and 5.5 ± 3 days respectively. Lastly, the success rate reached 95.2% Table 2 . Regarding postoperative complications in this group, they affected 3(14.3%) of patients, where, chest infection, wound infection, missed stones, and bile leak complicated 1(4.8%), 1(4.8%), 1(4.8%), and 2(9.5%) of them respectively; patients with chest and/or wound infection were managed conservatively(grade II according to Clavien grading), patient with missed stone was managed successfully percutaneously with choledochoscopic CBDE through the biliary drainage sinus tract under fluoroscopic control(grade III), however, the 2 cases with biliary leak were managed successfully conservatively as the leak was minor(grade II). Lastly, there was no stricture, recurrent stones or mortality during the long-term follow-up. Table 2 .
The incidence of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis varies widely in the literature between 5% and 33% according to age [, , , , ]. CBDS are either primary (originating within the CBD) or secondary (originating in the gallbladder) and pass into the CBD [6,7]. Trans-abdominal ultrasound (US) and magnetic resonance cholangiopancreatography (MRCP) are the most common non-invasive pre-operative imaging modalities for detection of CBDS .
For complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.
Despite development in endoscopic and laparoscopic techniques, OCBDE is still the choice in some hospitals in developing countries [20,58], in many surgical clinics , in eastern Europe , in many Asian countries,  and in some patients ((I.e. previous surgery with dense adhesions, aberrant biliary ductal anatomy, ……) [8,72]. Furthermore, it is indicated after failure of ERCP [18,26,33,41,73,74]. Similarly, after failure of ERCP, OCBDE was the main procedure in our institution (60/81; 74.1% if excluding converted cases, and 64/85; 75.3% if including them); the reason for this is that OCBDE was our usual operation as we started LCBDE very recently.
Comparison between patients with and without choledochoscope usage in OCBDE group: On univariate analysis, there was a significant correlation between intra-operative choledochoscope and the followings: Primary CBD repair, shorter operative time, shorter hospital stay, lower missed stones, and higher stone clearance rates. However, on multivariate analysis, there was an independent correlation between choledochoscope and performing primary repair of CBD after stone extraction. Table 5 .
After ERCP failure, the treatment options are either LCBDE or OCBDE [45,52,53]. Furthermore, they can be performed in the complex , and recurrent CBDS , because repeated ERCP has increased complication rate . Similarly, in our work, there was a significant correlation between the number of ERCP sessions and post ERCP complications.
ERCP: Endoscopic retrograde cholangio-pancreatography.