Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography: A large sample sized retrospective study

Abstract

BACKGROUND Recurrence of primary choledocholithiasis commonly occurs after complete removal of stones by therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The potential causes of the recurrence of choledocholithiasis after ERCP are unclear. AIM To analyze the potential causes of the recurrence of choledocholithiasis after ERCP. METHODS The ERCP database of our medical center for the period between January 2007 and January 2016 was retrospectively reviewed, and information regarding eligible patients who had choledocholithiasis recurrence was collected. A 1:1 case-control study was performed for this investigation. Data including general characteristics of the patients, past medical history, ERCP-related factors, common bile duct (CBD)-related factors, laboratory indicators, and treatment was analyzed by univariate and multivariate logistic regression analysis and Kaplan-Meier analysisly. RESULTS First recurrence of choledocholithiasis occurred in 477 patients; among these patients, the second and several instance (≥ 3 times) recurrence rates were 19.5% and 44.07%, respectively. The average time to first choledocholithiasis recurrence was 21.65 mo. A total of 477 patients who did not have recurrence were selected as a control group. Multivariate logistic regression analysis showed that age > 65 years (odds ratio [OR] = 1.556; P = 0.018), combined history of choledocholithotomy (OR = 2.458; P < 0.01), endoscopic papillary balloon dilation (OR = 5.679; P = 0.000), endoscopic sphincterotomy (OR = 3.463; P = 0.000), CBD stent implantation (OR = 5.780; P = 0.000), multiple ERCP procedures (≥2; OR = 2.75; P = 0.000), stones in the intrahepatic bile duct (OR = 2.308; P = 0.000), periampullary diverticula (OR = 1.627; P < 0.01), choledocholithiasis diameter ≥ 10 mm (OR = 1.599; P < 0.01), bile duct-duodenal fistula (OR = 2.69; P < 0.05), combined biliary tract infections (OR = 1.057; P < 0.01), and no preoperative antibiotic use (OR = 0.528; P < 0.01) were independent risk factors for the recurrence of choledocholithiasis after ERCP. CONCLUSION Patient age greater than 65 years is an independent risk factor for the development of recurrent choledocholithiasis following ERCP, as is history of biliary surgeries, measures during ERCP, and prevention of postoperative complications.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

“…Feng Deng et al (19) found that the diameter of choledocholithiasis ≥10 mm was an independent risk factor for the recurrence of choledocholithiasis after ERCP. The larger the stone diameter, the larger the bile duct dilatation.…”

“…67Although it has been confirmed that the diameter of common bile duct is a risk factor for the recurrence, the specific diameter has not yet been determined. Deng (19) and Park (65) believed 10mm, but Song (77) and Yoo (96) believe that the diameter of common bile duct≥15mm is a potential predictor after endoscopic stoning. It is worth mentioning that Jeon Jin et al (31) found that there is an inverse relationship between restoration of CBD diameter within two weeks and CBD stone recurrence.…”

“…Multiple ERCP operations also aggravate Oddi sphincter injury and increase the chance of retrograde infection. (20,49) Times of recurrence Park et al (64) conducted an average follow-up of 4.2 years among 46,181 south Korean patients with endoscopic choledocholithiasis, and found 5228 patients (11.3%) with first-time recurrence of choledocholithiasis. The recurrence rate was low for the first time, high for the second and third time, 23.4 % and 33.4 %, respectively.…”

“…Deng et al conducted a follow-up study on 477 patients with recurrent choledocholithiasis and found that the recurrence rate was as high as 19.5 %for the second recurrence and 44.07%for the third or more recurrence. (19) The possible reason is that multiple surgical treatments aggravate the injury of Oddi sphincter and induce the necrosis of bile duct epithelial cells, forming scars and leading to bile duct stricture. Local adhesions, resulting in bile duct angulation and cholestasis, lead to stone recurrence.…”

“…The incidence of cholelithiasis is 5% to 15%, in which the incidence of Choledocholithiasis is about 5%-30%. (19,71) Age, gender, genetic factors, factors related to metabolic syndrome, dietary factors ,and drugs are all risk factors for Choledocholithiasis. (43) At present, endoscopic cholangiopancreatography (ERCP) + endoscopic sphincterotomy (EST) is the most common treatment procedure.…”