The Usefulness of Multiple Double Pigtail Stents and Oral Ursodeoxycholic Acid in the Treatment of Difficult Bile Duct Stones

Abstract

Background: Large common bile duct (CBD) stones accompanied with risk factors can be difficult to extract by conventional techniques. When the extraction techniques have failed, temporary stenting is a technically easy and feasible method. Aim: Our study was to investigate the efficacy of combination therapy with multiple double pigtail stents and ursodeoxycholic acid (UDCA) as a prospective clinical trial. Materials and Methods: From September 2005 to September 2008, a total of 895 patients underwent attempted removal of CBD stones at our hospital. ERCP was performed using a video duodenoscope (TJF 240; Olympus, Japan). Difficult CBD stones were defined as those which could not be removed after sphincterotomy and/or balloon plasty by basket or balloon extraction, because of multiple or large stone (> 20 mm in diameter) accompanying with/without risk factors. Two or three double pigtail stents (7 or 10 Fr) were inserted into the bile duct over a guidewire with the proximal end above the stone and the distal end in the duodenum. The stents were left in place until endoscopic removal during a second attempt. All patients received oral UDCA (600 mg/day) during follow-up. Follow-up was performed every one or two months. Results: In 21 patients (2.34%), complete clearance was not achieved by the conventional method. There were 9 men and 12 women with a mean age of 73.8 years (range 38-88). Large (size > 20 mm, n=11) and multiple (n>3 and size > 10mm; n=16) stones, the presence of periampullary diverticulum limiting sphincterotomy (5), narrowing or stricture of distal CBD (3), and severe cardiopulmonary diseases (8) were found as limiting factors for stone removal in this study. Two stents were inserted in 13 patients and 3 stents in 8 patients. Complete endoscopic clearance was achieved in 12 patients (57.1%) and there was a statistically significant reduction in stone size (17.65 ± 4.20 mm vs. 13.04 ± 3.16 mm; p = 0.002). The mean duration (±SD) of stenting and medication was 73.9 (± 35.3) days. The outcomes for the remaining 9 patients were spontaneous migration of the stent with the stone (1), surgical operation (2), exchange of occluded stents (3), and remaining well with stents (3). There was no immediate complication related to the insertion of biliary stents. Conclusion: Our results suggest that combination therapy with multiple pigtail stenting and UDCA is an easy and effective method for difficult CBD stones and may not necessitate long-term care. However, this study was conducted using a limited number of patients and further prospective randomized controlled trials should be conducted.