Retrospective Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jan 16, 2017; 9(1): 26-33
Published online Jan 16, 2017. doi: 10.4253/wjge.v9.i1.26
Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones
Christos Konstantakis, Christos Triantos, Vasileios Theopistos, Georgios Theocharis, Ioannis Maroulis, Georgia Diamantopoulou, Konstantinos Thomopoulos
Christos Konstantakis, Department of Gastroenterology, General Hospital of Patras, 26335 Patras, Greece
Christos Konstantakis, Christos Triantos, Vasileios Theopistos, Georgios Theocharis, Ioannis Maroulis, Georgia Diamantopoulou, Konstantinos Thomopoulos, Department of Gastroenterology, University Hospital of Patras, 26504 Patras, Greece
Author contributions: Konstantakis C and Thomopoulos K contributed equally to this work; Konstantakis C collected and analyzed the data, and drafted the manuscript; Thomopoulos K provided analytical oversight; Thomopoulos K designed and supervised the study; Triantos C, Theopistos V, Theocharis G and Maroulis I revised the manuscript for important intellectual content; Triantos C and Thomopoulos K offered technical or material support; Triantos C and Diamantopoulou G provided administrative support; all authors have read and approved the final version to be published.
Institutional review board statement: The study was reviewed and approved by the Ethics committee of the University Hospital of Patras.
Informed consent statement: All study participants, or their legal guardian, provided written or verbal informed consent prior to study enrollment.
Conflict-of-interest statement: The Authors have nothing to declare.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at asraiah@yahoo.com.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Christos Konstantakis, MD, Department of Gastroenterology, General Hospital of Patras, 1 Tsertidou St, 26335 Patras, Greece. asraiah@yahoo.com
Telephone: +30-6974-563157 Fax: +30-2613-601893
Received: June 29, 2016
Peer-review started: July 1, 2016
First decision: August 22, 2016
Revised: September 17, 2016
Accepted: October 17, 2016
Article in press: October 19, 2016
Published online: January 16, 2017
Abstract
AIM

To evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease.

METHODS

All patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients’ files.

RESULTS

A total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 ± 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 ± 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 ± 6.9 mm vs 7.2 ± 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 ± 6.3 mm vs 12.0 ± 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence.

CONCLUSION

Bile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Keywords: Bile duct stone disease, Common bile duct angulation, Choledocholithiasis, Endoscopic retrograde cholangiopancreatography, Endoscopic sphincterotomy, Recurrence of choledocholithiasis

Core tip: Recurrence of choledocholithiasis is considered a late complication following endoscopic extraction of bile duct stones. There are various factors associated with the risk of recurrence. In our study the rate of recurrence was 13.5%. Although univariate analysis identified four different risk factors associated with both anatomical parameters (common bile duct diameter) and stone characteristics (stone size, use of mechanical lithotripsy, difficult lithiasis), multivariate analysis confirmed only bile duct diameter as being important. The underlying pathogenetic mechanism of recurrence is likely multifactorial in nature. Bile stasis, duodenal - biliary reflux and unfavorable stone characteristics probably contribute towards stone reformation.