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Available online xxx Keywords:Common bile duct stones Choledocholithiasis Single-stage treatment One-step treatment Transcystic approach Choledochotomy a b s t r a c t Background: Current evidence shows that single-stage treatment of concomitant choledocholithiasis and cholelithiasis is as effective and safe as two-stage treatment. However, several studies suggest that single-stage approach requires shorter hospitalization time and is more cost-effective than the two-stage approach, even though it requires considerable training. This study aimed to evaluate the implementation of a protocol for managing concomitant choledocholithiasis and cholelithiasis using single-stage treatment.Methods: A prospective cohort study of patients diagnosed with cholelithiasis and choledocholithiasis who were treated with the single-stage treatment e transcystic instrumentation, choledocotomy or intraoperative endoscopic retrograde cholangiopancreatography (ERCP) e between September 2010 and June 2017 was assessed. The primary outcomes were complications, hospital stay, operative time and recurrence rate.Results: 164 patients were enrolled. 141 (86%) were operated laparoscopically. Preoperatively diagnosed stones were not found by intraoperative imaging or disappeared after "flushing" in 38 patients (23.2%). Surgical approach was transcystic in 45 patients (27.41%), choledochotomy in 74 (45.1%), intraoperative ERCP in 4 (2.4%), and bilioenteric derivation in 3 (1.8%). Mean hospitalization stay was 4.4 days. Mean operative time was 166 min 27 patients (16.5%) had complications and 1 patient was exitus (0.6%). Recurrence rate was 1.2%. Conclusions:Single-stage approach is a safe and effective management option for concomitant cholelithiasis and choledocolithiasis. Furthermore, a significant number of common bile duct stones pass spontaneously to duodenum or can benefit from a transcystic approach, with presumable low morbidity and cost-efficiency.

Background: The optimal surgical resection strategy for colorectal cancer with synchronous liver metastases remains unclear. Length of stay is frequently used as an indicator of clinical effectiveness. However, this inaccurately reflects additional hospital stay for subsequent operations or re-admissions. This study adopts the`90-day cumulative length of stay' as a parameter to compare outcomes following simultaneous or staged resection strategies in this patient cohort. Material and Methods: A retrospective analysis was performed of patients undergoing either simultaneous or staged resections for colorectal cancer with synchronous liver metastases between 2009-2018. Patients undergoing ALPPS procedure were excluded. The post-operative hospital stay and re-admissions in the first 90 days post-op were recorded to define the`90-day cumulative length of stay'. Post-operative complications were also recorded using the Clavien-Dindo Classification to determine complication severity. Results: There were fifty-eight patients with a median age of 66 years (interquartile range (IQR): 56-75). Twentyseven patients underwent staged resections, whilst 31 patients underwent simultaneous resections. Thirty-three patients were male. Median cumulative length of stay was 11 (IQR= 9-16) days for simultaneous resection and 16 (IQR= 13-24) days in staged resections (p=0.002). Complication rates did not differ significantly between the two groups, 77.4% and 66.7% in simultaneous and staged resections respectively (p=0.835). Conclusion:This single-centre cohort study demonstrates a statistically significant benefit for simultaneous resection. 90-day cumulative length of stay is a suitable assessment tool for surgical management that may include sequential operations and possible readmissions for complication management. This has not been assessed previously in the context of synchronous colorectal liver metastases. Larger studies, ideally multi-centre randomised trials including subgroup analysis, are required for determining groups of patients that would derive the greatest benefit.

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