Prediction of recurrent choledocholithiasis by quantitative cholescintigraphy in patients after endoscopic sphincterotomy

Abstract

Background-Endoscopic sphincterotomy (EST) is widely used for the removal of stones from the bile duct, but stones recur in about one fifth of patients. Aims-To investigate hepatic clearance by quantitative cholescintigraphy (QC) in patients after EST and to discern the relationship between biliary emptying and stone recurrence. Methods-One hundred and forty nine patients who had EST and clearance of the bile duct for choledocholithiasis were selected. All patients were confirmed to have complete EST by sphincter of Oddi manometry and underwent QC soon after normalisation of liver function. Regular clinical follow up was performed for each patient. Results-During a mean 36 month follow up, 22 (14.8%) patients developed recurrent stones in the bile duct. Irrespective of the status of the gall bladder, patients with recurrent stones had a slower hepatic clearance of radioisotope during QC compared with patients without stone recurrence, but only the diVerences in cholecystectomised patients had statistical significance. After carrying out multivariate analysis, one parameter of QC, percentage clearance of maximal count at 45 minutes, was found to be the only significant factor for stone recurrence. All recurrent stones in the common bile duct were successfully removed at endoscopy. Conclusion-Slower hepatic clearance as shown by QC is an important factor responsible for stone recurrence after sphincter ablation.

An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

“…Angulation along the course of the CBD may predispose to bile stasis and thus promote stone formation and recurrence. Indeed, bile stasis is thought to be an important factor in the pathogenesis of bile duct stones [2,3,5,9,13]. Duct dilation, the other risk factor observed, also may promote stasis, and thereby support the notion of its pathogenetic importance.…”

The role of endoscopy in the management of choledocholithiasis

“…209 Fortunately, recurrent CBD stones can be managed at ERC with a high rate of success. 204,210 In patients with documented CBD stone recurrence, biliary stasis and its predisposing factors may be difficult to definitively correct, and alternative management strategies can be considered. In a small series of 13 patients with 2 or more documented recurrences of CBD stones, a decision to perform annual surveillance ERC for duct sweeping was associated with a reduction in the frequency of ascending cholangitis.…”

Management of common bile-duct stones and associated gallbladder stones: surgical aspects

“…56,57 This is illustrated by the fact that most recurrent CBD stones are brown pigment stones, of which the pathogenesis is associated with bactobilia. 58 The reasons for delayed biliary clearance are largely unknown, but abnormal biliary motility has been suggested in cholecystectomised patients.…”