Date Published: July 10, 2017
Publisher: Public Library of Science
Author(s): Shin Kato, Kenji Chinen, Susumu Shinoura, Kaoru Kikuchi, Naoya Sakamoto.
Predictors for bile duct stone recurrence after endoscopic stone extraction have not yet been clearly defined and a study investigating naïve major duodenal papilla is warranted because studies focusing only on naïve major duodenal papilla are rare. The aim of this study was to observe the long-term outcomes of endoscopic bile duct stone extraction for naïve major duodenal papilla and to assess the predictors for recurrence.
This was a retrospective cohort study that consisted of 384 patients with naïve papilla who underwent initial endoscopic bile duct stone extraction. Patients were followed up in outpatient department subsequent to complete stone clearance. Recurrence was defined as symptomatic repeated stone formation observed at least three months after the procedure. Stone recurrence, predictors of recurrence, and the recurrence rate, depending on each endoscopic treatment for major duodenal papilla, were examined.
In this study, 34 patients (8.9%) developed stone recurrence. The median time to recurrence was 439 days. Periampullary diverticulum and multiple stones were strong predictors of bile duct stone recurrence (RR, 5.065; 95% CI, 2.435–10.539 and RR: 2.4401; 95% CI: 1.0946–5.4396, respectively). The above two factors were independent predictors of stone recurrence as per logistic regression analysis adjusted for confounders (Periampullary diverticulum: OR, 7.768; 95% CI, 3.27–18.471; multiple stones: OR, 4.144; 95% CI, 1.33–12.915). No recurrence was observed after endoscopic papillary large balloon dilatation (0/20), whereas recurrence was observed in 7 patients after endoscopic papillary balloon dilatation (7/45) and in 27 patients after endoscopic sphincterotomy (27/319). However, these differences were not statistically significant (p = 0.105).
We determined that the presence of periampullary diverticulum and multiple stones are strong predictors for recurrence after endoscopic stone extraction. Moreover, endoscopic papillary large balloon dilatation tended to be correlated with non-recurrence of bile duct stone.
Techniques for endoscopic bile duct (BD) stone extraction are well established and efficacious, and the complete clearance rate of ordinary sized BD stones is approximately 92%–100% [1, 2]. However, recurrence of BD stones occurs in approximately 10% of patients after endoscopic stone extraction.
From January 2009 to November 2014, 578 consecutive patients underwent endoscopic retrograde cholangiopancreatography (ERCP) for BD stone extraction in a 550 beds, tertiary referral center located in Japan. Among them, 157 patients were excluded because of previous ERCP history, and 19 patients were excluded because of previous history of choledocojejunostomy. While 402 patients had initial endoscopic BD stone extraction for naïve major duodenal papilla, 13 of them did not have regular follow up after stone extraction and were therefore excluded. In addition, five patients could not complete the required follow-up period (3 months) because of death from primary disease (pancreatic cancer, 1; lung cancer, 1; malignant lymphoma, 1; and urosepsis, 2). Thus, 384 patients were included in this retrospective, observational study (Fig 1).
There were 200 men and 184 women in this study, and the mean age was 70.8 years old. The median follow up period was 1098 days (ES, 1160 days; EPBD, 1216 days; EPLBD, 789 days. range, 92–2552 days). Additionally, 136 patients (35.4%) had PAD, and 10 patients had type 1 PAD (in which the major duodenal papilla is located inside the diverticulum), 33 patients had type 2 (major duodenal papilla is located on the edge of the diverticulum), 91 patients had type 3 (major duodenal papilla is located on the outside of the diverticulum), and 2 patients had unknown/undetermined type of PAD due to lack of records. In our cohort, 319 patients had ES before stone extraction, 45 patients had EPBD, and 20 patients had EPLBD. Mean diameters of stone and BD were 7.4 mm (range, 3–35 mm), and 10.3mm (range, 4–25 mm), respectively. Procedural mean time was 42.9 min (range 7–158 min). The number of BD stones were as follows; 1 stone, 212 patients; 2 stones, 39 patients; 3 stones, 28 patients; 4 stones, 15 patients; 5 stones, 7 patients; 6 stones, 12 patients; 7 stones, 8 patients; 8 stones, 4 patients; sludge, 59 patients. (Table 1).
In this study, we found that the recurrence rate of BD stones during follow up period was 8.9%, and the presence of PAD and multiple BD stones were strong predictors of recurrence.