Recurrent Common Bile Duct Stones Research Articles

Su1599 Rate of Duodenal-Biliary Reflux Increases in Patients With Recurrent Common Bile Duct Stones: the Direct Evidence From Barium Meal Examination

Stone recurrence is a common late adverse event after ERCP in patients with common bile duct stone (CBDS). Duodenal-biliary reflux (DBR) is considered one of the major causes of CBDS recurrence due to chronic inflammation of biliary duct. However, the direct evidence is still lacking.

Clinical study of trans-T tube duodenal papilla balloon dilatation: a novel procedure for postsurgical residual common bile duct stone

To investigate the safety and efficacy of trans-T tube duodenal papilla balloon dilatation for the removal of residual common bile duct stone after choledocholithotomy and T tube drainage. Thirteen cases with residual common bile duct stone treated with trans-T tube duodenal papilla balloon dilatation in our department from June 2010 to April 2012 were analyzed retrospectively. Record CA19-9, bilirubin and albumin before the procedure, 1 week and 1 month later. Check if immediate complications occurs, including hemorrhage, perforation, pancreatitis and cholangitis. During the following up for 2 years, stone recurrence, reflux cholangitis and other long-term complications were observed. Analyze the changes of indicators between preoperative and postoperative and the correlation. All of the 13 patients were treated successfully. 11 patients underwent one procedure, and 2 patients received twice or more times of procedures. CA19-9 decreased significantly 1 week later and 1 month later compared with those before the procedure, while ALB was opposite. Incidences of biliary tract infection and hemorrhage were 1 and 1 respectively. No severe complications occurred, including perforation of gastrointestinal or biliary tract. Incidences of recurrent stone and reflux cholangeitis were 2 and 1 in two years after the procedure. Trans-T tube duodenal papilla balloon dilatation is a safe and effective procedure for patients with recurrent common bile duct stone after choledocholithotomy and T-tube drainage. For the cases which could not be handled with endoscopic procedures, it provides a new therapeutic approach.

Risk Factors for the Presence of Residual Bile Duct Stones after Endoscopic Treatment of Stones of the Common Bile Duct

목적: 총담관담석의 내시경 제거술 이후 발생하는 잔여담석은 재발성 총담관담석으로 발현하거나 총담관담석으로자라는데 핵으로 작용할 수 있다. 그러나 관련된 위험인자에관한 연구는 드물다. 본 연구의 목적은 총담관담석의 내시경제거술 후 잔여 담석과 관련이 있는 인자들을 확인하고자하였다. 방법: 2008년 7월부터 2013년 6월까지 부산백병원에서 총담관담석으로 생애 처음 내시경 제거술을 시행 받은 환자중 잔여 담석이 발견된 환자 55명, 잔여 담석이 발견되지 않은 환자 281명을 선정하여 후향적으로 환자 대조군 연구를시행하였다. 두 군 간의 나이, 성별, 총담관담석의 성상, 혈액학적 검사 결과, 유두부 주위 게실의 유무, 기계식 쇄석술시행 유무, 유두부 풍선확장술 단독 사용 유무, 다발성 총담관담석의 동반 유무, 총담관담석의 크기, 총담관의 직경, 담낭 담석의 존재 유무, 이전에 담낭 절제술 시행 유무, 총담관담석의 내시경 제거술 시행 후 담낭 절제술 시행 여부를 비교 분석하였다. 결과: 단변량 분석에서 기계식 쇄석술을 시행 받은 경우,10 mm 이내의 유두부 풍선확장술만을 시행한 경우, 다수의총담관담석을 제거한 경우, 총담관담석의 크기가 1 cm보다큰 경우가 잔여 담석의 위험인자로 확인되었다. 다변량 분석에서 10 mm 이내의 유두부 풍선확장술만을 시행한 경우(OR, 3.174; p = 0.000), 4개 이상의 총담관담석을 제거한 경우(OR, 2.459; p = 0.013)가 잔여 담석의 발생에 관여하는 독립적인 위험인자로 확인되었다. 결론: 10 mm 크기 이내의 유두부 풍선확장술 단독 사용,4개 이상의 총담관담석이 동반된 경우가 총담관담석의 내시경 제거술 후 잔여 담석의 발생과 관련된 독립된 위험인자이고 이런 인자들이 동반된 환자의 시술 시 더욱 주의를 기울임과 동시에 2차 내시경 역행 담췌관조영술을 고려해야하겠다.

Second laparoscopic surgery vs endoscopic retrograde cholangiopancreatography for treatment of recurrent common bile duct stones: A randomized study

Second laparoscopic surgery vs endoscopic retrograde cholangiopancreatography for treatment of recurrent common bile duct stones: A randomized study

Reappraisal of endoscopic papillary balloon dilation for the management of common bile duct stones.

Although endoscopic sphincterotomy (EST) is still considered as a gold standard treatment for common bile duct (CBD) stones in western guideline, endoscopic papillary balloon dilation (EPBD) is commonly used by the endoscopists in Asia as the first-line treatment for CBD stones. Besides the advantages of a technical easy procedure, endoscopic papillary large balloon dilation (EPLBD) can facilitate the removal of large CBD stones. The indication of EPBD is now extended from removal of the small stones by using traditional balloon, to removal of large stones and avoidance of lithotripsy by using large balloon alone or after EST. According to the reports of antegrade papillary balloon dilatation, balloon dilation itself is not the cause of pancreatitis. On the contrary, adequate dilation of papillary orifice can reduce the trauma to the papilla and pancreas by the basket or lithotripter during the procedure of stone extraction. EPLBD alone is as effective as EPLBD with limited EST. Longer ballooning time may be beneficial in EPLBD alone to achieve adequate loosening of papillary orifice. The longer ballooning time does not increase the risk of pancreatitis but may reduce the bleeding episodes in patients with coagulopathy. Slowly inflation of the balloon, but not exceed the diameter of bile duct and tolerance of the patients are important to prevent the complication of perforation. EPBLD alone or with EST are not the sphincter preserved procedures, regular follow up is necessary for early detection and management of CBD stones recurrence.

Size of recurrent symptomatic common bile duct stones and factors related to recurrence.

Some common bile duct (CBD) stones recur after endoscopic stone extraction. Little information is available on the size and recurrence interval of recurrent symptomatic CBD stones or on ways to prevent recurrence. Between January 2007 and December 2011, consecutive 481 patients undergoing endoscopic extraction of CBD stones at a single institute were enrolled. We selected 34 patients with recurrent symptomatic CBD stones and 63 patients who were followed up more than five years without recurrence. The sizes of the CBD stones increased during the recurrences: 10.1±5.2 mm, 13.5±7.3 mm, and 16.8±7.8 mm at the initial presentation, the first recurrence, and the second recurrence, respectively (p=0.016). Among CBD stone recurrences, 50% occurred within 2.3 years, and 80% occurred within 5.3 years. The recurrence group had a smaller proportion of patients under 50 years of age, larger CBD diameters, less histories of more than 10 mm endoscopic papillary large-balloon dilation (EPLBD), and more type I periampullary diverticula, compared with the non-recurrence group (p<0.05). Multivariate analysis revealed that EPLBD more than 10 mm and smaller CBD diameter were independently related to less recurrence of CBD stones (p=0.001 and 0.012, respectively). The sizes of CBD stones increased during recurrences. EPLBD more than 10 mm and smaller CBD diameter were related to less recurrence of CBD stones.

Prevention of pancreatitis after papillary balloon dilatation by nasobiliary drainage: a randomized controlled trial.

Endoscopic papillary balloon dilation (EPBD) was associated with a higher rate of endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). The purpose of this study was to determine whether placement of an endoscopic nasobiliary drainage (ENBD) catheter can also prevent PEP after EPBD. A total of 93 patients, who with proven common bile duct (CBD) stones, received EPBD were enrolled this trial. They were randomly divided into ENBD group (n = 45) and no-ENBD group (n = 48) according whether undergone an ENBD procedure after EPBD. Their demographics, laboratory, procedural data were collected, and pancreaticobiliary complications were followed. The number of patients with serum amylase levels above the normal upper limit (>180 U/L) did not differ between groups. However, compared with ENBD group, more patients in No-ENBD group had levels greater than three times the normal limit (>540 U/L) (11/48 vs 3/45, P = 0.0285), and more patients developed to PEP (7/48 vs 0/45, P = 0.0250). During follow-up, the numbers of patients undergone cholecystectomy, cholangitis and recurrence of CBD stones were similar. There was also no significant difference in the cumulative rate of recurrent pancreaticobiliary complications between the two groups (P = 0.452). EPBD followed by insertion of an ENBD catheter can prevent PEP, and routine ENBD catheter placement is recommended after an EPBD procedure.

Late Complications following Endoscopic Sphincterotomy for Choledocholithiasis: A Swedish Population-Based Study.

In order to assess the risk of long-term complications following endoscopic sphincterotomy (ES) for common bile duct stones (CBDS), we conducted a cohort study. The study included 1,113 patients who underwent ES for CBDS in six different hospitals in central Sweden between 1977 and 1990. Through the use of the Swedish population registry, each patient was assigned five population-based controls matched for sex and age. Linkage to the Inpatient Registry yielded information on morbidity and mortality for the patients as well as for the controls. After one year of washout, there were 964 patients available for follow-up. The mean age was 70.6 years, 57% were women, and the mean length of follow-up was 8.9 years. The patients' overall morbidity was significantly higher and we observed a tendency towards increased mortality as well. Recurrent CBDS was diagnosed in 4.1% of the patients. Acute cholangitis with a hazard ratio (HR) of 36 (95%CI 11–119.4) was associated with recurrent CBDS in 39% of the patients. HR for acute pancreatitis was 6.2 (95%CI 3.4–11.3) and only one patient had CBDS at the same time. In conclusion, we consider acute pancreatitis and cholangitis both as probable long-term complications after ES.

Role of endoscopic papillary balloon dilation in patients with recurrent bile duct stones after endoscopic sphincterotomy

BackgroundEndoscopic sphincterotomy (ES) is an established treatment for patients with choledocholithiasis or common bile duct stones (CBDS), but further management of patients after ES with recurrent CBDS remains controversial. Endoscopic papillary large balloon dilation (EPLBD) has been used safely and effectively for stone removal in patients after ES with recurrent CBDS. The aim of this study was to evaluate the clinical efficacy of EPLBD in patients after complete ES with recurrent CBDS. MethodsRecords of 891 patients with CBDS after complete ES from January 1991 to December 2008 were reviewed. Of 133 patients with recurrent CBDS, 122 had complete endoscopic bile duct clearance. Twenty-three patients (Group 1) underwent EPLBD and 99 (Group 2) underwent stone extraction without dilatation. Basic demographics and endoscopic findings at the first recurrence were recorded and analyzed. The primary end point was the second CBDS recurrence. ResultsNo statistical differences were observed between the two groups, except for larger CBDS size in Group 1. The bile duct clearance rate was 96% in Group 1 and 91% in Group 2. No complications such as pancreatitis, perforation, and bleeding were noted in Group 1, and one patient in Group 2 suffered from bleeding after stone extraction. The rate of second recurrent CBDS after endoscopic clearance for the first recurrent CBDS was 17% in Group 1 and 60% in Group 2 (p < 0.001). There were two independent factors for the second recurrence, including cirrhosis (odds ratio 4.734, p = 0.023) and stone extraction directly without major papilla expansion (odds ratio 6.050, p = 0.003). ConclusionEPLBD is a safe and effective endoscopic treatment for recurrent CBDS in patients after ES. It can also facilitate complete clearance of CBDS and prevent further CBDS recurrence.

Tu1954 Risk Factors of Recurrence of Common Bile Duct Stones After Removing With Endoscopic Papillary Large Balloon Dilatation

Background/Aims: Endoscopic papillary large balloon dilation (EPLBD) can be used as a treatment of removing the difficult common bile duct (CBD) stone. However, we still experience cases of recurrence after an EPLBD. The aim of this study was to evaluate the risk factors of recurrence of CBD stone after an EPLBD. Methods: From March 2004 to October 2010, a total of 262 patients with CBD stones were treated by EPLBD at Gangnam Severance and Daegu Catholic University Hospital. Clinical and endoscopic parameters were analyzed to determine the risk factors of CBD stone recurrence. Results: Of the 262 patients (men 100, women 162, mean age 72.0±11.8 years), the recurrence rate was 19.8% ( 52/ 262). Mean duration between treatment and recurrence was 13.5 months (1.4~64.8 months). In univariate analysis, multiple stones (≥3), large stone (≥14mm), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°) were identified as the significant predictors of recurrence. In multivariate analysis, multiple stones (≥3, P=0.015, OR 2.26, 95% CI 1.174.36), diameter of CBD (≥ 20mm, P < 0.001, OR 4.67, 95% CI 2.23-9.80) and angulated CBD (angle≤145°, P < 0.001, OR 4.98, 95% CI 2.36-10.54) were identified as the significant predictors of recurrence. Gender, age, periampullary diverticulum and previous cholecystectomy did not influence the recurrence rate. Conclusions: The recurrence of CBD stone after EPLBD was strongly associated with multiple stones (≥3), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°). Close and meticulous follow-up may be required in patients with these parameters.

Tu1957 The Association Study Between Histopathologic Features of the Gallbladder Wall and Cholescintigraphy in Patients With Atypical Biliary Pain

Background/Aims: Endoscopic papillary large balloon dilation (EPLBD) can be used as a treatment of removing the difficult common bile duct (CBD) stone. However, we still experience cases of recurrence after an EPLBD. The aim of this study was to evaluate the risk factors of recurrence of CBD stone after an EPLBD. Methods: From March 2004 to October 2010, a total of 262 patients with CBD stones were treated by EPLBD at Gangnam Severance and Daegu Catholic University Hospital. Clinical and endoscopic parameters were analyzed to determine the risk factors of CBD stone recurrence. Results: Of the 262 patients (men 100, women 162, mean age 72.0±11.8 years), the recurrence rate was 19.8% ( 52/ 262). Mean duration between treatment and recurrence was 13.5 months (1.4~64.8 months). In univariate analysis, multiple stones (≥3), large stone (≥14mm), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°) were identified as the significant predictors of recurrence. In multivariate analysis, multiple stones (≥3, P=0.015, OR 2.26, 95% CI 1.174.36), diameter of CBD (≥ 20mm, P < 0.001, OR 4.67, 95% CI 2.23-9.80) and angulated CBD (angle≤145°, P < 0.001, OR 4.98, 95% CI 2.36-10.54) were identified as the significant predictors of recurrence. Gender, age, periampullary diverticulum and previous cholecystectomy did not influence the recurrence rate. Conclusions: The recurrence of CBD stone after EPLBD was strongly associated with multiple stones (≥3), diameter of the CBD (≥ 20mm), and angulated CBD (angle≤145°). Close and meticulous follow-up may be required in patients with these parameters.

Single-Stage vs. Two-Stage Management for Concomitant Gallstones and Common Bile Duct stones: A Prospective Randomized Trial with Long-Term Follow-up

AimThe preferred approach to the management of common bile duct (CBD) stones is uncertain, with single-stage laparoscopic cholecystectomy and CBD exploration vs. two-stage preoperative endoscopic CBD clearance followed by laparoscopic cholecystectomy being debated. To address this, a prospective randomized study which compared these two management strategies was undertaken. MethodsBetween Jan 2002 and Dec 2005, patients with gallstones and common bile duct stones diagnosed by preoperative ultrasonography and magnetic resonance cholangiopancreatography were randomized to single-stage vs. two-stage treatment. In a single-stage group, laparoscopic cholecystectomy and CBD exploration were undertaken at the same operation, whereas in a two-stage group, endoscopic stone clearance was followed by laparoscopic cholecystectomy 2–5 days later. Early treatment success and complications and longer-term follow-up for the two groups were compared. ResultsTwo hundred twenty-one patients were enrolled in the trial, 110 in the single-stage group and 111 in the two-stage group. There was no significant difference in the success rate of CBD clearance (93.6 vs. 94.6 %, p = 0.76) or the complication rates (3.6 vs. 5.1 %, p = 0.527) between the groups. However, at longer-term follow-up, recurrent CBD stones were seen more often in the two-stage group (9.5 vs. 2.1 %, p = 0.037). ConclusionThe single-stage and two-stage approaches were equally effective in achieving initial clearance of CBD stones. However, recurrent CBD stones occurred more commonly in patients who had undergone two-stage treatment with initial endoscopic stone clearance, followed by laparoscopic cholecystectomy.

Primary common bile duct closure after open exploration for choledocholithiasis

Background: Choledocholithiasis is the second-most common complication of cholecystolithiasis, occurring in approximately 10-15% of patients. For choledocholithiasis, there are two methods for CBD exploration to extract stones: either endoscopically, by endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy, or surgically, by an open or laparoscopic method Open CBD exploration has been the principal treatment in many hospitals and is still considered the gold standard for the removal of CBD stones. Following common bile duct (CBD) exploration and stone removal, the choice for closure of the incised bile duct lies between primary closure and T-tube drainage. There are many papers reported by different authors, which support the direct closure of the duct immediately after exploration. The aim ofthis study was to assess the clinical short-term results and benefits of primary closure of the common bile duct after open choledochotomy for CBD calculi in a developing country like Egypt. Methods: Between December 2010 and December 2013; 74 patients with a radiological evidence of common bile duct stones were admitted and treated at the Gastrointestinal Surgery Unit, Main Alexandria University Hospitalin whom the common bile duct diameter was equal to or larger than 8 mm. Those associated with distal CBD strictures, multiple intrahepatic calculi, or malignancy were excluded After approval of local ethics committees, all patients included in this study were informed well about the operative procedure and an informed written consent was obtained from every patient before carrying the procedure. All patients' data, surgical procedures, complications and follow-up details were collected and analyzed Results: CBD exploration and stone removal followed by primary closure was performed in all patients. The mean age of patients was 55.3 ±15.7 years {range, 37-75 years). Most of the patients presented with biliary colic (74%). Sixty-seven patients {90%) had concomitant gallstones as evident by preoperative abdominal ultrasound The mean diameter of CBD was 12.3 ±3.2mm {range, 8-27mm). Themaximumnumberofstoneswas 14. The total complication rate was 54% (4174) and included wound infection with delayed wound healing and bileleakage. One patient had a bile leakage that subsided on the third postoperative day. There was no post­ operative biliary obstruction, residual stones, cholangitis, pancreatitis, biliary peritonitis or intra-abdominal collections. The mean postoperative hospital stay was 4.2 ± 1 days. There was no perioperativemortality. The mean durationof follow-up was 10.8 ± 3.2 months {range, 4-18 months). There was no recurrence of CBD stones or stricture of bile ducts observed during the follow up period and postoperative ultrasound findings were normal. Conclusion: Primary closure of the CBD after open choledochotomy for choledocholithiasis is safe, feasible and effective with shorter hospital stays and lower costs.

Clinical Practice Guidelines for Common Bile Duct Stones: The Endoscopic Management of Difficult and Recurrent Common Bile Duct Stones

Clinical Practice Guidelines for Common Bile Duct Stones: The Endoscopic Management of Difficult and Recurrent Common Bile Duct Stones

Long-term follow-up of different endoscopic strategies in management of choledocholithiasis in young patients

Objective To investigate the rate of stone recurrence in young patients with common bile duct （CBD） stones after removal of stones by different endoscopic strategies and the risk factors of re- cent and long-term CBD stone recurrence. Methods After successful CBD stones removal in one ERCP ses- sion, young patients （aging 21-45 years） with complete follow-up data were recruited to the study. They were divided into endoscopic papillary balloon dilation （EPBD） group, endoscopic sphincterotomy （EST） group and EST ＋ EPBD group according to the endoscopic approaches they experienced. The recent （ ≤3 years） and long-term （ 〉 3 years） recurrent frequencies of CBD stone were counted, and the possible risk factors were determined with multivariate logistic regression analysis. Results A total of 327 young pa- tients were followed up at a mean duration of 76. 5 months, and CBD stone re-occurred in 54 cases （16. 5% ） , among which, the recent recurrence was 35 cases （ 10. 7% ） and the long-term recurrence was 19 cases （5.8%）. The recent CBD stone recurrence rates in EPBD group and the EST group were higher than that of EST ＋ EPBD group but with no significant difference （ P all 〉 13.05 ）. The long-term CBD stone recurrence rates in EPBD group and the EST group were significantly higher than that of the EST ＋ EPBD group （P all 〈 0. 05 ）. Logistic regression analysis showed that, gallbladder stone, the maximum diameter of the stone, the stone number and mechanical lithotripsy were significantly related to the recent CBD stone recurrence （P 〈 0. 05 ）. The long-term CBD stone recurrence was significantly related to the maximum diameter of the stone and balloon dilatation alone （P 〈 0. 05 ）. Conclusion Removal of CBD stones by EPBD a- lone for young patients may preserve the papillary sphincter function, but would increase the risk of long-term CBD stone recurrence. Small endoscopic sphincterotomy plus EPBD could significantly reduce the CBD stone recurrence rate. Key words: Choledocholithiasis; Endoscopic papillary balloon dilation; Sphincterotomy, endoscopic ; Follow-up studies

Small endoscopic sphincterotomy plus large-balloon dilation for removal of large common bile duct stones during ERCP

This study compared the therapeutic benefits and complication rates of small endoscopic sphincterotomy plus large-balloon dilation (ESLBD) with those of endoscopic sphincterotomy (EST) alone for large bile duct stones. We compared prospectively ESLBD group (n=63) with conventional EST group (n=69) for the treatment of large bile duct stones (≥15mm). Mechanical lithotripsy was performed when the stone could not be removed using a normal basket. We compared the rates of stone removal, frequency of mechanical lithotripsy use, procedure-related complications, and recurrent stones. A total of 132 patients were reviewed in the study. The mean age of the patients was 67.9 years. The two groups showed significant differences in complete stone removal during the first session (80.9 vs. 60.8%; P = 0.046), the use of mechanical lithotripsy (7.94 vs. 24.6%; P = 0.041), and less duration of admission (P =0.045). After ERCP, there were some instances of oozing in both groups, All patients recovered completely, 14 patients had recurrent common bile duct stones among the follow-up duration. The ESLBD technique seems to be a feasible and safe alternative technique for conventional EST and EBD and has no more Post-ERCP complications.

Size and type of periampullary duodenal diverticula are associated with bile duct diameter and recurrence of bile duct stones

Periampullary diverticula (PAD) are not uncommon findings during endoscopic retrograde cholangiopancreatography, but its clinical significance had not been established. To investigate the clinical characteristics associated with PAD and their relationships with the type and size of PAD in patients with common bile duct (CBD) stones was aimed. Three hundred seventy patients undergoing endoscopic retrograde cholangiopancreatography between March 2010 and July 2012 were consecutively enrolled, and their demographics, laboratory data, and CBD stone-related characteristics according to PAD type and PAD size were analyzed. Mean age, mean size of CBD stones, prevalence of systemic inflammatory response syndrome, and serum C-reactive protein level differed in patients with CBD stones according to the presence or absence of PAD. The presence of PAD and positive blood culture were correlated with systemic inflammatory response syndrome (P = 0.033 and P < 0.001, respectively). The recurrence of CBD stones was more frequent, and the diameter of CBD was larger in patients with PAD type I than in those with PAD type III. Mean age and CBD diameter were lower in patients with PAD size < 15 mm than those with PAD size ≥ 15 mm. Multivariate analyses indicated that CBD diameter was related to PAD size (P = 0.002) and the recurrence of CBD stones was related to PAD type (P = 0.001). PAD are associated with larger CBD stones and severe cholangitis with CBD stones. CBD diameter is related to PAD size, and the recurrence of CBD stones is related to PAD type.

Risk factors for recurrent common bile duct stones after ERCP

Objective To reveal the related risk factors of recurrent common bile duct （CBD） stones after ERCP. Methods Collected the patients data who underwent ERCP from January 2009 to December 2009 for CBD stones. The factors including gender, age, body mass index （BMI） , initial course of disease, history of biliary tract surgery, gallstones, papillary diverticulum, diameter of CBD, number of stones, size of stone and biliary stricture were compared between patients with recurrent CBD stone （recurrent group） or without （control group） by comparative analysis and multivariate logistic regression analysis. Results A total of 190 patients were followed up with a mean duration of 2. 3 years, with 68 patients in recurrent group and 122 in control. The comparative analysis showed that age （ 65.5 ± 15.5 yr vs. 57.6 ± 15.4 yr,P = 0. 001 ） , initial course of disease （ P = 0. 015 ） , history of biliary tract surgery （ 17.6% vs. 2. 5% ,P = 0. 000 ）, papillary diverticulum （ 29.4% vs. 7. 4%, P = 0. 000 ）, diameter of CBD （ 15.0 ± 5.1 mm vs. 10.7 ±3.4 mm,P =0. 001 ） , number of stones≥2 （80. 9% vs. 72. 9% ,P =0. 000） , diameter ofstone≥10 mm （35.3% vs. 8.2%,P=0.000） and biliary stricture （32.3% vs. 13.9%, P=0. 000） were statistically different between 2 groups. Multivariate analysis showed an older age （ OR = 3.44,95% CI： 1.55-7.63,P = 0. 002） , previous biliary surgery （OR = 5.82,95 % CI：I. 34-25.29,P = 0. 019） , having papillary diverticulum （ OR = 3.29,95 % CI： 1.18-9. 12, P = 0. 022 ）, diameter of CBD ≥ 10 mm（ OR = 4. 30, 95 % CI： 1.72-10. 72, P = 0. 002 ） , number of stones ≥ 2 （ OR = 4. 24,95 % CI： 1.61-11.16, P = 0. 003 ） are independent risk factors for recurrence of CBD stones. Conclusion An older age, previous biliary surgery history, papillary diverticulum, diameter of CBD ≥ 10 mm and number of stones ≥ 2 are independent risk factors for recurrence of CBD stones. Key words: Cholangiopancreatography, endoscopic retrograde ; Choledocholithiasis ; Recur-rence ; Risk factors ; Comparative study

Large balloon dilation for the treatment of recurrent bile duct stones prevents short‐term recurrence in patients with previous endoscopic sphincterotomy

Our previous study revealed the efficacy and safety of the large balloon dilation (LBD) technique. However, there is insufficient objective data about the recurrence rate. The aim of this study was to compare the recurrence rate of common bile duct (CBD) stones between patients treated with and without LBD. Patients with recurrent CBD stones treated between April 2006 and August 2010, and who had a history of endoscopic sphincterotomy (ES), were enrolled. Patients were excluded if they had a CBD diameter of less than 10 mm or if the diameter of their largest CBD stone was <10 mm. A total of 62 consecutive patients were investigated. From April 2006 to November 2007, 32 patients were treated without LBD (non-LBD group; historical control). From December 2007 to August 2010, 30 patients underwent LBD (LBD group). The median follow-up times in the LBD and non-LBD groups were 517 and 1034 days (p < 0.001), respectively. Kaplan-Meier analysis revealed a significantly lower incidence of recurrent CBD stones in the LBD group than in the non-LBD group (p = 0.048). LBD reduces the short-term recurrence of CBD stones in patients with previous ES.

Long-term follow-up study of gallbladder in situ after endoscopic common duct stone removal in Korean patients

Although there has been much debate over the fate of the gallbladder (GB) after endoscopic common bile duct (CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stones to prevent further biliary complications. The aims of this study were to assess the natural course of the patients with GB in situ after endoscopic CBD stone removal and to evaluate the necessity of prophylactic cholecystectomy. Four hundred sixty-one patients who had undergone CBD stone removal at Yeungnam University Hospital between January 2000 and December 2004 were retrospectively analyzed, and 232 patients were ultimately enrolled in this study. The mean duration of follow-up was 73 (range = 7-126) months in the cholecystectomy group and 66 (6-127) months in the GB in situ group (p = 0.168). Ten patients (14.7 %) in the cholecystectomy group and 31 patients (18.9 %) in the GB in situ group developed recurrent CBD stones (p = 0.295). The highest percentage of recurrent CBD stones in both groups was that for brown stones (80 and 80.6 %). In the GB in situ group, cumulative recurrence rates of CBD stones were not significantly different between patients with GB stones and without GB stones (15.9 vs. 20 %, p = 0.798). However, the incidence of acute cholecystitis was significantly higher in patients with GB stones compared to patients without GB stones (13.6 vs. 2.5 %, p = 0.003). Prophylactic cholecystectomy seems to be unnecessary in patients without GB stones after endoscopic sphincterotomy. However, in patients with GB stones, elective cholecystectomy or close observation is recommended due to the higher risk of cholecystitis.