Prevalence and Risk Factors for Choledocholithiasis After Cholecystectomy

Abstract

Introduction: Clinical manifestations of choledocholithiasis include biliary colic, obstructive jaundice, pancreatitis, and acute cholangitis. Prior studies have suggested that presentations of these conditions within 3 years of cholecystectomy (CCY) are more likely due to residual stones missed at time of surgery as opposed to formation of recurrent stones. Complications of retained common bile duct (CBD) stones are well recognized, however there is limited data on pattern and time of presentation. The aim of this study was to determine the pattern of presentation in patients with and without prior CCY. Methods: A retrospective chart review was conducted of patients with biliary pancreatitis, acute cholangitis, or symptomatic choledocholithiasis at a secondary and tertiary care center over a two-year period. The electronic medical record was reviewed to collect the following data: age, sex, race, body mass index, history of CCY and perioperative bile duct evaluation, presence of CBD stone or sludge, and endoscopic retrograde cholangiopancreatography (ERCP) results including maximum CBD diameter and presence of periampullary duodenal diverticulum. Results: 358 patients with biliary pancreatitis, acute cholangitis, or biliary colic due to choledocholithiasis were assessed (Table 1). 100 (27.9%) patients were post-CCY prior to presentation. Demographic and clinical data were reviewed (Table 2). Patients with or without a CCY presented with: 32 (12.4%) vs 6 (6.0%) for biliary pancreatitis (P= 0.078), 33 (12.8%) vs 32 (32.0%) for acute cholangitis (P< 0.001), and 196 (76.0%) vs 62 (62.0%) for symptomatic choledocholithiasis (P=0.008), respectively. Post-CCY patients with a known procedure date had a median recurrence of choledocholithiasis of 210 days with 24 (80%) requiring an ERCP within 3 years.Table: Table. Comparison of Presentation of Choledocholithiasis Between Patients with and Without a CCYTable: Table. Demographic and Clinical DataConclusion: Recurrent biliary obstruction due to post-CCY choledocholithiasis is not uncommon. The disproportionate prevalence of acute cholangitis in post-CCY patients is multifactorial. Given the frequency of gallstone-related disease recurrence within 3 years after CCY, the role of pre-CCY cholangiography should be re-evaluated in future studies. Specifically, the identification of risk factors that predispose patients to recurrent disease would assist in standardization of perioperative CBD evaluation, with a goal of preventing further episodes.