Background and Aims Acute obstructive suppurative cholangitis (AOSC) is a severe biliary tract infection characterized by rapid onset and progression, for which timely relief of biliary obstruction is essential. With the development of laparoscopic techniques, laparoscopic common bile duct exploration (LCBDE) has become an important surgical approach for common bile duct stones. After stone extraction, primary suture (PS) or T-tube drainage (TD) can be used to manage the common bile duct incision; however, the clinical efficacy and safety of these two approaches in patients with AOSC remain incompletely defined. In particular, postoperative bile leakage is an important complication of LCBDE-PS that may adversely affect postoperative recovery. Therefore, identification of its risk factors and risk stratification are of clinical importance. This study aimed to compare the clinical efficacy of LCBDE plus PS and LCBDE plus TD in patients with AOSC, identify factors associated with postoperative bile leakage after LCBDE plus PS, and develop a prediction model for postoperative bile leakage to provide a reference for surgical decision-making and postoperative risk assessment.Methods The clinical data of 186 patients with AOSC admitted to Wuwei People's Hospital from January 2023 to December 2025 were retrospectively analyzed. Among them, 96 patients underwent LCBDE with primary suture (LCBDE-PS group), while 90 underwent LCBDE with T-tube drainage (LCBDE-TD group). Perioperative outcomes, postoperative complications, and stone recurrence at 5 months after surgery were compared between the two groups. Patients in the LCBDE-PS group were further divided into a bile leakage group (n=11) and a non-bile leakage group (n=85) according to the occurrence of postoperative bile leakage. Clinical and laboratory parameters were compared between the two groups. Multivariate Logistic regression analysis was performed to identify independent factors associated with postoperative bile leakage after LCBDE-PS, and a nomogram prediction model was subsequently constructed. The Hosmer-Lemeshow goodness-of-fit test, receiver operating characteristic (ROC) curve, and decision curve analysis (DCA) were used to evaluate the model's goodness of fit, discriminative ability, and clinical net benefit, respectively.Results Compared with the LCBDE-TD group, the LCBDE-PS group had shorter operative time, less intraoperative blood loss, shorter drainage-tube indwelling time, lower total abdominal drainage volume, and shorter postoperative hospital stay (all P<0.05). No significant differences were observed between the two groups in the incidence of postoperative complications or stone recurrence during follow-up (all P>0.05). Within the LCBDE-PS group, patients with bile leakage had higher preoperative direct bilirubin levels and longer operative times, but lower preoperative albumin levels and smaller common bile duct diameters than those without bile leakage (all P<0.05). Multivariate Logistic regression analysis showed that a larger common bile duct diameter (OR=0.658, 95% CI=0.505-0.857, P=0.002) and higher preoperative albumin level (OR=0.719, 95% CI=0.550-0.940, P=0.016) were associated with a lower risk of postoperative bile leakage, whereas higher preoperative direct bilirubin level (OR=1.435, 95% CI=1.161-1.773, P=0.001) and longer operative time (OR=2.037, 95% CI=1.092-3.799, P=0.025) were associated with an increased risk. The nomogram incorporating these four factors showed good model fit. The area under the ROC curve was 0.949 (95% CI=0.901-0.997), with a sensitivity of 90.91% and specificity of 89.41%. DCA indicated a positive net clinical benefit of the model across a threshold probability range of 0.03-0.96.Conclusion Compared with LCBDE plus TD, LCBDE plus PS may provide favorable perioperative outcomes for patients with AOSC without increasing postoperative complications or short-term stone recurrence. Common bile duct diameter, preoperative albumin level, preoperative direct bilirubin level, and operative time were associated with postoperative bile leakage after LCBDE plus PS. The nomogram based on these factors showed good discriminative performance and may assist in postoperative risk stratification for bile leakage.