Original Article/Biliary
Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study

https://doi.org/10.1016/j.hbpd.2021.04.011Get rights and content

Abstract

Background

Recurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone.

Methods

We performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone.

Results

In univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69–55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05–318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00–1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19–0.81, P = 0.012) was a protective factor.

Conclusions

We identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.

Introduction

The prevalence of common bile duct stones ranges from 11% to 25% in patients with gallbladder stones [1] and approximately 10% of patients undergoing cholecystectomy will have concomitant common bile duct (CBD) stones [2]. Gallstone diseases represent a prominent cause for gastrointestinal related hospital admission [3]. CBD stones may result in severe and life-threatening conditions including pancreatitis, cholangitis and sepsis which can deteriorate to death [4]. Endoscopic retrograde cholangiopancreatography (ERCP) is currently the most commonly used and preferred method for definitive treatment of CBD stones, as endoscopic sphincterotomy (EST) followed by stone extraction with balloon or basket has been used traditionally as a standard technique [5]. However, laparoscopic surgical exploration of the bile duct is highly successful and presents similar morbidity [6]. Although ERCP is a well-established and highly efficacious modality for definitive bile duct stones removal, with complete stones clearance rate reaching 92%–100% [7], recurrent CBD stones after endoscopic clearance by the standard techniques is a well-known sequel of ERCP, which is defined by stones detected more than 6 months following the index ERCP [8,9], encountered in almost 10% of patients [10]. Other study reported a recurrence rate ranging from 4% to 24%, when the recurrence interval was up to 15 years period [11].

To date, proposed predictors of recurrent CBD stone after endoscopic stone extraction include dilated bile ducts, large stones, multiple stones, and periampullary diverticulum (PAD) [10], and a recent study has shown that acute angulation of the distal CBD was a strong predictor of recurrent CBD stone [12]. However, data regarding these associations are still scarce. Therefore, we aimed to explore parameters that may be associated with recurrent CBD stone (diagnosed > 6 months after the index ERCP) among patients who underwent ERCP and definitive stone extraction.

Section snippets

Methods

A retrospective case control study was conducted on patients who underwent ERCP for documented CBD stone at Galilee Medical Centre, Nahariya, Israel from January 2010 to December 2019. Inclusion criteria were: 1) patients who were older than 18 years of age, 2) diagnosed with CBD stone by radiological modalities, and 3) underwent ERCP procedure including EST plus stone extraction by balloon, basket or both, with definitive stone extraction as defined by normal cholangiogram performed after

Baseline demographics, clinical and endoscopic characteristics

Overall, 949 patients were enrolled, among whom 492 were excluded due to several causes: 17 patients with failed ERCP, 63 patients with repeated ERCP due to retained stone, 202 patients with pancreato-biliary malignancies, 57 patients with post-operative leak, 53 patients with stent exchange, and 100 patients lack of data. A total of 457 patients were included in the final analysis (Fig. 1). Forty-two patients (9.2%) had recurrent CBD stone (group A), and 415 patients (90.8%) did not have

Discussion

Although most patients with gallstones remain asymptomatic, about 10%–25% do become symptomatic, mostly as a result of stone migration into the CBD [14]. Of these, 1%–2% develop major complications [15]. ERCP represents the treatment modality of choice for CBD stone removal despite its potential complications. One of the major concerns of stone removal is a retained or recurrent stone with its own potential for complications, especially in the elderly comorbid patient, necessitating a repeat

Acknowledgments

None.

CRediT authorship contribution statement

Wisam Sbeit: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Anas Kadah: Data curation, Formal analysis, Resources. Matta Simaan: Data curation, Formal analysis. Amir Shahin: Data curation, Formal analysis, Resources. Tawfik Khoury: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision,

Funding

None.

Ethical approval

The study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institution Human Research Committee (0140-18-NHR).

Competing interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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