Predictors for bile duct stone recurrence after endoscopic extraction for naïve major duodenal papilla: A cohort study

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review

Background

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow-up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those.

Methods

A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors.

Results

A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2-13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in-situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement.

Conclusion

Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow-up in high-risk patients.

Comparison Study between ERCP and PTBD for Recurrent Choledocholithiasis in Patients Following Gastrectomy

The recurrence rate of choledocholithiasis in the general population has been reported to exceed 10%. The incidence of cholelithiasis was reported to be higher in patients following gastrectomy than that in the general population. However, there is no study for recurrent choledocholithiasis incidence in patients following gastrectomy. This study aimed to evaluate the recurrence rate of choledocholithiasis and identify risk factors for recurrent choledocholithiasis in patients following gastrectomy. A retrospective analysis was performed on patients with gastrectomy history who underwent choledocholithiasis removal in Kyungpook National University Hospital between January 2011 and December 2019. Choledocholithiases were treated by endoscopic retrograde cholangiopancreatography (ERCP) (n = 41) or percutaneous transhepatic biliary drainage (PTBD) (n = 90). The gastrectomy type was classified as subtotal gastrectomy with Billroth I (18.3%), Billroth II (45.0%), and total gastrectomy with Roux-en-Y (36.6%). During a median follow-up period of 31.5 (range, 6-105) months, choledocholithiasis recurrence was noted in 19 of 131 patients (14.5%). In subgroup analysis, the ERCP group (24.4%) had higher choledocholithiasis recurrence than the PTBD group (10.0%). Stone removal modality (ERCP), no use of balloon sphincteroplasty, and the presence of periampullary diverticulum were significant risk factors for recurrent choledocholithiasis. In multivariate analysis, ERCP (hazard ratio (HR), 3.597; 95% confidence interval (CI): 1.264-10.204) CBD stricture (HR, 3.823; 95% CI: 1.118-13.080) and no use of balloon sphincteroplasty (HR, 4.830; 95% CI: 1.669-13.889) were risk factors for recurrent choledocholithiasis following stone removal. The incidence of CBD stones in patients who underwent gastrectomy is similar to that of the general population. ERCP, CBD stricture, and no use of balloon sphincteroplasty are potential risk factors for recurrent CBD stones following gastrectomy. When we consider PTBD disadvantages, the ERCP procedure with active use of balloon sphincteroplasty is recommended to decrease recurrent CBD stones.

Comparing Stone Recurrence Following Surgical Common Bile Duct Exploration or Endoscopic Stone Extraction for Patients with Common Bile Duct Stones

Background: Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. Results: A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, P = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], P < .001) following multivariate regression. Conclusion: Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

New common bile duct morphological subtypes: Risk predictors of common bile duct stone recurrence

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment for removing common bile duct (CBD) stones. The risk factors for CBD stone recurrence after ERCP have been discussed for many years. However, the influence of CBD morphology has never been noticed.

AIM

To evaluate CBD morphology and other predictors affecting CBD stone recurrence in average patients.

METHODS

A retrospective analysis of 502 CBD stone patients who underwent successful therapeutic ERCP for stone extraction at our centre from February 2020 to January 2021 was conducted. CBD morphology and other predictors affecting CBD stone recurrence were examined by univariate analysis and multivariate logistic regression analysis.

RESULTS

CBD morphology (P < 0.01), CBD diameter ≥ 1.5 cm [odds ratio (OR) = 2.20, 95%CI: 1.08-4.46, P = 0.03], and endoscopic biliary sphincterotomy with balloon dilation (ESBD) (OR = 0.35, 95%CI: 0.17-0.75, P < 0.01) are three independent risk factors for CBD stone recurrence. Furthermore, the recurrence rate of patients with the S type was 6.61-fold that of patients with the straight type (OR = 6.61, 95%CI: 2.61-16.77, P < 0.01). The recurrence rate of patients with the polyline type was 2.45-fold that of patients with the straight type (OR = 2.45, 95%CI: 1.14-5.26, P = 0.02). The recurrence rate of S type patients was 2.70-fold that of patients with the polyline type (OR = 2.70, 95%CI: 1.08-6.73, P = 0.03). Compared with no-ESBD, ESBD could decrease the risk of recurrence.

CONCLUSION

CBD diameter ≥ 1.5 cm and CBD morphology, especially S type and polyline type, were associated with increased recurrence of CBD stones. In addition, ESBD was related to decreased recurrence. Patients with these risk factors should undergo periodic surveillance and standard prophylactic therapy.

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

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.

Differences in Outcome and Comparison of Stress and Immune Status in Patients with Recurrent Common Bile Duct Stones after Biliary Tract Surgery Choosing Three Procedures (ERCP, OCBDE, and LCBDE) for Treatment

OBJECTIVE

To compare the effect of choosing ERCP, OCBDE, and LCBDE for the treatment of patients with recurrent common bile duct stones after biliary tract surgery.

METHOD

115 patients with recurrent common bile duct stones after biliary surgery in our hospital were retrospectively analyzed and divided into three groups according to the procedure, 36 patients in the ERCP group, 38 patients in the OCBDE group, and 41 patients in the LCBDE group, and compared the efficacy, stress status, and immune status of the three groups.

RESULT

The stone removal rates were 91.67%, 97.37%, and 97.56% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). There were statistical differences between the ERCP, OCBDE, and LCBDE groups in terms of operative time, postoperative recovery time of exhaustion, recovery time of defecation, recovery time of feeding, and hospitalization time (P < 0.05). The postoperative complication rates were 8.33%, 10.53%, and 7.32% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). The recurrence rates within 1 year after surgery were 2.78%, 7.89%, and 2.44% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05).

CONCLUSION

ERCP has short operative time, short hospital stay, and rapid postoperative recovery. LCBDE has mild trauma, and OCBDE has a wide range of application. Each of the three procedures has its own advantages and shortcomings, and the most appropriate procedure should be selected on the basis of comprehensive evaluation.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

Choledocholithiasis is a chronic common disease. The incidence of cholelithiasis is 5%-15%, of which 5%-30% are combined with Choledocholithiasis. Although endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure, which clearance rate is up to 95%, the incidence of recurrent choledocholithiasis was 4%-25%. The risk factors of recurrence after choledocholithiasis clearance are the focuses of current researches, which are caused by multiple factors. We first systematically summarize the risk factors of common bile duct stones (CBDS) recurrence into five aspects: first-episode stone related factors, congenital factors, biological factors, behavioral intervention factors, and the numbers of stone recurrence.

Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video)

BACKGROUND AND STUDY AIMS

Endoscopic treatment outcomes for hepatolithiasis in patients with altered anatomy are not well known. The aim of this study was to evaluate the treatment outcomes of hepatolithiasis in patients with hepaticojejunostomy (HJ) using short-type double-balloon endoscopy (sDBE) and to assess the risk factors for stone recurrence.

PATIENTS AND METHODS

This was a retrospective cohort study that consisted of 73 patients with hepatolithiasis who underwent bowel reconstruction with HJ at an academic center. Stone removal was performed using sDBE. After balloon-occluded cholangiography using sDBE, peroral direct cholangioscopy (PDCS) using ultraslim endoscopy was performed to check for residual stones, depending on the bowel reconstruction method. Recurrence was defined as the development of cholangitis from stones.

RESULTS

The success rate of reaching the HJ site was 92% (67/73), and the complete stone removal rate was 93% (62/67) with multiple sessions (mean number 1.5 ± 0.9). The occurrence rate of procedure-related adverse events was 6.8%. Among 58 patients evaluated for stone recurrence, 13 (22%) developed recurrence during a median follow-up period of 2.7 years (interquartile range: 1.5-4.8). Multivariate analyses determined that a stone diameter ≥ 8 mm [odds ratio (OR), 5.57; 95% confidence interval (CI), 1.39-37.2; p = 0.013] and performing PDCS (OR, 0.16; 95% CI, 0.0084-0.90; p = 0.036) were significant factors for stone recurrence.

CONCLUSIONS

Endoscopic treatment using sDBE for hepatolithiasis was effective and safe. PDCS might reduce the rate of stone recurrence by detecting stones that are too small to confirm on fluoroscopic images.

Multiple recurrences after endoscopic removal of common bile duct stones: A retrospective analysis of 976 cases

BACKGROUND AND AIM

Recurrences after endoscopic treatment of common bile duct stones (CBDS) are common. The aims of this study were to identify risk factors for recurrences of CBDS and to evaluate the effect of interventions for prevention of further recurrences.

METHODS

A total of 976 patients who underwent endoscopic treatment of CBDS were retrospectively studied. Risk factors for single and multiple recurrent CBDS were evaluated using a Cox hazard regression model. The incidences of further recurrences were evaluated according to the additional interventions.

RESULTS

The mean age was 69.3 years, and 39.3% were female. Endoscopic papillary balloon dilation, endoscopic sphincterotomy, and endoscopic papillary large balloon dilation were performed in 858, 77, and 41 patients, respectively. The rates of one or more recurrence and multiple recurrences of CBDS were 12.4% and 2.7%, respectively. In the multivariate analyses, the significant risk factors were the bile duct size (hazard ratio [HR] 1.07, P = 0.012), gallbladder left in situ with stones (HR 1.91, P = 0.046), and pneumobilia after treatment (HR 2.10, P = 0.047) for single recurrence and the number of stones at the first recurrence (HR 1.16, P = 0.021) for multiple recurrences. In five out of nine cases with multiple recurrences, further recurrence was not observed after additional sphincteroplasty in addition to cholecystectomy.

CONCLUSIONS

The incidence of multiple recurrences was not uncommon after the first recurrence of CBDS.

Papillary balloon dilatation combined with endoscopic sphincterotomy for treatment of common bile duct stones: Efficacy and factors affecting stone recurrence

AIM

To evaluate the efficacy of endoscopic papillary balloon dilatation (EPBD) combined with endoscopic sphincterotomy (EST) in the treatment of common bile duct stones and to identify the factors affecting the recurrence of stones.

METHODS

One hundred patients with choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) at our hospital between January 2014 and January 2016 were randomly divided into a control group and an experimental group. The patients in the control group and experimental group were given EST lithotomy and small-incision endoscopic sphincterotomy (SEST) combined with EPBD, respectively. The one-time success rate, total success rate, and the incidence of complications after ERCP were comparatively analyzed. The Kaplan-Meier survival curve of patients with postoperative stone recurrence was plotted, and the Cox regression model was used to explore the risk factors for postoperative recurrence in patients.

RESULTS

The maximum diameter of the stones (t = -1.055, P = 0.294), the rate of multiple stones (χ² = 0.644, P = 0.422), the maximum diameter of bile duct (t = -0.820, P = 0.414), and the stone removal success rate (94.0% and 100.0%, χ² = 1.375, P = 0.241) differed significantly between the control group and the experimental group. There was no significant difference in the one-time success rate between the control group and the experimental group (84.0% and 96.0%, χ² = 4.332, P = 0.037). The incidence of complications after ERCP in the control group and experimental group was 17.02% and 6.0%, respectively (χ² = 4.337, P = 0.036). A total of 97 patients were followed, with stone recurrence occurring in 11 cases. In the 97 patients followed, the incidence of complications after ERCP in the control group and experimental group was 17.02% and 6.0%, respectively (χ² = 2.927, P = 0.087). Log-rank test showed that the risk of gallstone recurrence in the experimental group was significantly lower than that in the control group (HR = 0.285, 95%CI: 0.095-0.888, P = 0.044). Multivariate Cox regression analysis showed that multiple endoscopic procedures, common bile duct angulation (≤ 145°), and EST were risk factors for ERCP recurrence.

CONCLUSION

The success rate and safety of EPBD combined with LEST in the management of common bile duct stones are high, and the risk of long-term stone recurrence is low. Multiple endoscopic operations and common bile duct angulation (≤ 145°) are risk factors for stone recurrence.