Original Article/BiliaryPredictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study
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.
References (28)
- et al.
Predicting common bile duct stones by non-invasive parameters
Hepatobiliary Pancreat Dis Int
(2020) - et al.
Success rate and complications of endoscopic extraction of common bile duct stones over 2 cm in diameter
Hepatobiliary Pancreat Dis Int
(2011) Natural history of asymptomatic and symptomatic gallstones
Am J Surg
(1993)- et al.
Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients
Gastrointest Endosc
(2006) - et al.
Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy
Gastrointest Endosc
(2021) - et al.
Role of liver function tests in predicting common bile duct stones in acute calculous cholecystitis
Br J Surg
(2005) - et al.
A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited
Ann Surg
(2004) - et al.
The burden of gastrointestinal and liver diseases, 2006
Am J Gastroenterol
(2006) - et al.
Endoscopic papillary large balloon dilatation with sphincterotomy is safe and effective for biliary stone removal independent of timing and size of sphincterotomy
World J Gastroenterol
(2017) Laparoscopic common bile duct exploration: practical application
Arch Surg
(1998)