Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

Abstract

BACKGROUND A previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography. AIM To determine whether saline irrigation can improve CBD clearance after lithotripsy. METHODS This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy. RESULTS Between October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation ( P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD ( P = 0.004). CONCLUSION Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial

“… 10 Our previous prospective self-controlled study of 47 patients who underwent lithotripsy and stone removal by ERCP found that although there were no stone residues on cholangiography, SpyGlass DS found that there were no stone fragments or biliary sludge residues in only 15% of the cases. 11 Taken together, the literature and our previous study show that cholangiography after endoscopic extraction does not detect residual stone fragments and biliary sludge. These tiny missed stone fragments become one of the reasons for stone recurrence.…”

“… 7 , 9 , 10 , 12 Our previous study confirmed that 94% of patients were free of stone fragments and biliary sludge after intermittent irrigation with 100 ml saline. 11 However, there are few reports about residual stone fragments and the recurrence of CBDS. Whether saline irrigation can reduce the recurrence of stones after endoscopic stone removal has not been confirmed by prospective randomized controlled trials.…”

Stone removal by percutaneous papillary balloon dilatation for cystic duct and bile duct stones after cholecystectomy and distal gastrectomy with Roux-en-Y gastrojejunostomy

“…Even in the usual cases of bile duct stones without Roux-en-Y reconstruction, the recurrence rate of bile duct stones after endoscopic stone removal has been reported 4% - 24%. The incidence of residual stones after mechanical lithotripsy for intractable bile duct stones is 24%-40% [1] . In clinical practice, recurrent cholangitis due to residual bile duct stones occurs frequently even after endoscopic stone removal [2] .…”

“…Endoscopic treatment is now widely used as the first choice for bile duct stones [1] , [2] , [3] , [4] . With advances in endoscopic technology, endoscopists are actively challenging bile duct stone removal in patients who have undergone Roux-en-Y reconstruction or Billroth's operation II [5 , 6] .…”

Preferable timing of intraductal ultrasonography during endoscopic retrograde cholangiopancreatography lithotomy: A prospective cohort study

“…Accordingly, this may result in prolonged hospital stay in certain cases. According to statistics, the residual rate of stones can reach 12.9% ( 7 , 8 ). Several factors contribute to the residual of stones, including the presence of multiple stones, debris from lithotripsy, and other stone-related characteristics ( 9 ).…”