Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms

doi:10.1016/S0016-5107(98)70085-9

Gastrointestinal Endoscopy

Volume 48, Issue 5, November 1998, Pages 457-464

Presented in part at the annual meeting of the American Society for Gastrointestinal Endoscopy, May 1997, Washington DC (Gastrointest Endosc 1997;45:A143).

https://doi.org/10.1016/S0016-5107(98)70085-9 Get rights and content

Abstract

Background: The long-term outcome after endoscopic papillotomy is poorly defined. The aim of this study was to determine the long-term results of this method in the treatment of common duct calculi and to determine which prognostic factors are associated with the relapse of biliary symptoms. Methods: Between 1985 and 1988, 223 consecutive (149 women, mean age 67.9 years) patients underwent endoscopic papillotomy for duct stones; 127 had already undergone cholecystectomy or underwent this operation during the same hospitalization. Follow-up data were obtained retrospectively from the patients and patients' relatives and general practitioners. Results: The procedure was successful in 217 of 223 cases (97%), of which 203 were followed-up; 2 patients died in the first month after treatment (0.89%). Mean follow-up for the 201 patients was 6.2 years, during which 31 relapsed (15%). Three significant prognostic factors for late complications were identified in a multivariate analysis. The recurrence rate of biliary symptoms in patients who were left with an in situ gallbladder was 20.2%, and 11% for those whose gallbladder was removed (p = 0.04). Patients with a bile duct 15 mm or greater in diameter were more prone to recurrence of symptoms than those with a bile duct 10 mm or less in diameter (41% vs. 10%, p = 0.025) and were especially at higher risk to develop recurrent stones (19.5% vs. 4.9%, p = 0.019). Stone recurrence, but not biliary symptoms as a whole, was more frequent in patients with a peripapillary diverticulum (p = 0.035). Conclusions: The long-term results of endoscopic papillotomy are comparable with those of surgical techniques. The prognostic factors associated with relapse of biliary symptoms as a whole are gallbladder left in situ and choledochal diameter. Bile duct size and peripapillary diverticula are associated with recurrent bile duct stones. (Gastrointest Endosc 1998;48:457-64.)

Section snippets

PATIENTS AND METHODS

Between April 1985 and June 1988, 243 patients were referred to our department for endoscopic treatment of bile duct stones. Twenty patients were excluded from the analysis for the following reasons: 2 had concomitant primary sclerosing cholangitis; 10 had no common duct stone by cholangiography and so did not undergo papillotomy; and in 8 patients endoscopic access to the papilla was impossible (Billroth II gastrectomy = 7, pyloric stenosis = 1). Papillotomy and duct clearance were achieved in

RESULTS

Long-term outcome (between 7 and 10 years) was determined for 201 of the 223 patients, 14 cases being lost to follow-up (6.5% of the sample); in 6 cases the procedure failed and the patients were treated surgically, and 2 patients died less than 30 days after EPT (Fig. 1).

. Synopsis of outcomes after endoscopic papillotomy.

DISCUSSION

With the advent of LC there has been an increase in combined laparoscopic and endoscopic treatment of biliary lithiasis, in an effort to maintain the minimally invasive approach, although some prospective randomized studies in the pre-laparoscopic era demonstrated that combined treatment was not better than surgery alone.21, 22 Laparoscopic common duct exploration is also being developed²³ and the choice between laparoscopy and endoscopy is disputed. The use of EPT in younger patients and even

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2023, Hepatobiliary and Pancreatic Diseases International
The risk factors for the recurrent choledocholithiasis after endoscopic retrograde cholangiopancreatography (ERCP) have not been well studied. The aim of this study was to explore the risk factors of recurrent choledocholithiasis.
We carried out a retrospective analysis of data collected between January 1, 2010 and January 1, 2020. Univariate analysis and multivariate analysis were used to explore the independent risk factors of recurrent choledocholithiasis following therapeutic ERCP.
In total, 598 patients were eventually selected for analysis, 299 patients in the recurrent choledocholithiasis group and 299 patients in the control group. The overall rate of recurrent choledocholithiasis was 6.91%. Multivariate analysis showed that diabetes [odds ratio (OR) = 3.677, 95% confidence interval (CI): 1.875-7.209; P < 0.001], fatty liver (OR = 4.741, 95% CI: 1.205-18.653; P = 0.026), liver cirrhosis (OR = 3.900, 95% CI: 1.358-11.201; P = 0.011), history of smoking (OR = 3.773, 95% CI: 2.060-6.908; P < 0.001), intrahepatic bile duct stone (OR = 4.208, 95% CI: 2.220-7.976; P < 0.001), biliary stent (OR = 2.996, 95% CI: 1.870-4.800; P < 0.001), and endoscopic papillary balloon dilation (EPBD) (OR = 3.009, 95% CI: 1.921-4.715; P < 0.001) were independent risk factors of recurrent choledocholithiasis. However, history of drinking (OR = 0.183, 95% CI: 0.099-0.337; P < 0.001), eating light food frequently (OR = 0.511, 95% CI: 0.343-0.760; P = 0.001), and antibiotic use before ERCP (OR = 0.315, 95% CI: 0.200-0.497; P < 0.001) were independent protective factors of recurrent choledocholithiasis.
Patients with the abovementioned risk factors are more likely to have recurrent CBD stones. Patients who eat light food frequently and have a history of drinking are less likely to present with recurrent CBD calculi.
One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more
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The management strategy for common bile duct stones (CBD) in patients over 75 years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients.
This study included eighty-two patients over 75 years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n = 40) or by sequential endoscopy and surgery (ES group, n = 42).
Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P = 0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (> 3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively.
The “surgery alone” attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.
Response
2019, VideoGIE
Endoscopic management of postcholecystectomy biliary leak: When and how? A nationwide study
2019, Gastrointestinal Endoscopy
ERCP is considered the first-line therapy for biliary duct leaks (BDLs). However, the optimal ERCP timing and endotherapy methods remain controversial. Our aim was to evaluate these factors as predictors of poor clinical outcomes after BDLs.
Adults who underwent ERCP for BDLs after cholecystectomy were identified from the Nationwide Inpatient Sample from 2000 to 2014. ERCP was classified as emergent, urgent, and expectant if it was done within 1 day, after 2 to 3 days, or >3 days after BDLs, respectively. Endotherapy was classified into sphincterotomy, stent, or combination. Post-ERCP adverse events (AEs) were defined as requiring pressor infusion, endotracheal intubation, invasive monitoring, or hemodialysis. Early endotherapy failure was defined as the need for salvage surgical or radiology-percutaneous biliary intervention after ERCP.
A total of 1028 patients with a median age of 56 years were included. ERCP was done emergently (19%), urgently (30%), and expectantly (51%). Endotherapy procedures were sphincterotomy (24%), biliary stent (24%), and combination (52%). Post-ERCP AEs were 11%, 10%, and 9% for emergent, urgent, and expectant ERCP, respectively (P = .577). In-hospital mortality showed a U-shape trend of 5%, 0%, and 2% for emergent, urgent, and expectant ERCP, respectively (P < .001). Combination and stent monotherapy had lower failure rates of 3% and 4%, respectively as compared with sphincterotomy monotherapy with failure rate of 11% (P < .001). When multivariate analysis was used, both combination (odds ratio, .2; 95% confidence interval, .1-.5) and stent monotherapy (odds ratio, .4; 95% confidence interval, .2-.9) were less likely to fail as compared with sphincterotomy monotherapy. There were no statistically significant differences between combination therapy and stent monotherapy in the univariate and the multivariate analyses.
Although limited by retrospective design and the possibility of selection bias, this analysis suggests that the timing of ERCP is not a significant predictor of post-ERCP AEs after BDLs. Furthermore, combination or stent monotherapy had lower failure rates as compared with sphincterotomy monotherapy.
Long-term outcomes of endoscopic papillary balloon dilation for removal of bile duct stones in Billroth II gastrectomy patients
2018, Hepatobiliary and Pancreatic Diseases International
Endoscopic papillary balloon dilation (EPBD) for common bile duct (CBD) stones removal in Billroth II gastrectomy patients is feasible. However, the long-term outcomes of this technique are not clear. The aim of this study was to evaluate the procedural and long-term outcomes of EPBD for removal of CBD stones in Billroth II gastrectomy patients.
The records of patients with previous Billroth II gastrectomy referred for CBD stones removal with endoscopic retrograde cholangiopancreatography (ERCP) between July 1, 2008 and September 1, 2016 were retrospectively reviewed. The main outcomes of stone clearance, ERCP-related adverse events, and stone recurrence were analyzed.
A total of 83 patients with previous Billroth II gastrectomy underwent ERCP in our center were reviewed. Forty-nine consecutive patients with previous Billroth II gastrectomy referred to EPBD for removal of CBD stones underwent 59 ERCP procedures were enrolled in the end. The overall successful CBD stones clearance was achieved in 42 patients (85.7%). ERCP-related adverse events was in 3 ERCP procedures (5.1%). Severe complications, including perforation and bleeding, were not observed. Six of 49 patients (12.2%) had stone recurrence after a median period of 22.5 months (range 6–71 months) from the end of stone removal treatment. Female [odds ratio (OR) = 11.352; 95% confidence interval (95% CI): 1.040–123.912; P = 0.046] and previous mechanical lithotripsy (OR = 13.423; 95% CI: 1.070–168.434; P = 0.044) were significantly associated with stone recurrence.
At long-term follow-up, EPBD for removal of CBD stones appeared to be safe and effective in Billroth II gastrectomy patients. Female and previous mechanical lithotripsy may be risk factors for stone recurrence.
Choledocholithiasis recurrence following laparoscopic common bile duct exploration
2019, Cirugia Espanola
La coledocolitiasis puede tratarse mediante abordaje endoscópico por colangiopancreatografía endoscópica retrógrada o realizando una exploración laparoscópica de la vía biliar principal (ELVBP) durante la colecistectomía. La recurrencia de la coledocolitiasis y sus factores de riesgo tras extracción endoscópica han sido ampliamente investigados. Nuestro objetivo es analizar los factores de riesgo asociados con la recurrencia de cálculos en la vía biliar principal después de una ELVBP.
Los pacientes que se sometieron a ELVBP desde febrero de 2004 a julio de 2016 fueron examinados en un análisis univariante y multivariante para estudiar la asociación de recurrencia de coledocolitiasis con las siguientes variables: sexo; edad; presencia de hepatopatía; dislipemia, obesidad, o diabetes mellitus; cirugía abdominal previa; presencia de colecistitis, colangitis o pancreatitis al diagnóstico; pruebas de función hepática preoperatorias, número de cálculos recuperados; método de limpieza y cierre del conducto biliar común; presencia de litiasis coledocianas impactadas o intrahepáticas; conversión a cirugía abierta y morbilidad postoperatoria.
Se incluyeron 156 pacientes. La tasa de recurrencia de la coledocolitiasis fue del 14,1%, con un tiempo medio de recurrencia de 38,18 meses. La edad fue el único factor de riesgo independiente para la recurrencia de cálculos en el análisis univariante y multivariante. Ningún paciente menor de 55 años desarrolló nuevos cálculos en la vía biliar principal, y el 86,4% de las recurrencias se produjo en pacientes mayores de 65 años.
La edad es el único factor de riesgo independiente asociado a la recurrencia de coledocolitiasis después de ELVBP. Diferentes mecanismos en el desarrollo de cálculos en la vía biliar principal pueden estar presentes para pacientes más jóvenes y de edad más avanzada.
Choledocholithiasis may be treated following an endoscopic approach or by laparoscopic common bile duct exploration (LCBDE). Stone recurrence following endoscopic management has been extensively investigated. We analyze the risk factors associated with stone recurrence following LCBDE.
Patients who underwent LCBDE from February 2004 to July 2016 were examined in an univariate and multivariate analysis to assess the association of stone recurrence with the following variables: gender; age; hepatopathy; dyslipidemia, obesity or diabetes mellitus; previous abdominal surgery; presence of cholecystitis, cholangitis or pancreatitis; preoperative liver function tests, number of retrieved stones; method of common bile duct clearance and closure; presence of impacted or intrahepatic stones; conversion to open surgery and postoperative morbidity.
A total of 156 patients were included. Recurrence rate for choledocholithiasis was 14.1% with a mean time to recurrence of 38.18 month. Age was the only independent risk factor for stone recurrence at univariate and multivariate analysis. No patient aged under 55 years developed new common bile duct stones, and 86.4% of the recurrences occurred in patients aged above 65.
Age is the only independent risk factor associated to choledocholithiasis recurrence following LCBDE. Different mechanism in common bile duct stone development may be present for younger and older patients.

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^☆: From the Department of Medicine C (Gastroenterology-Hepatology) of the Klinikum Ludwigshafen, Academic Teaching Hospital of the University of Mainz, Ludwigshafen, Germany.

^☆☆: Supported by grants of the Brazilian Ministry of Education (CAPES Foundation) and the German Academic Exchange Program (DAAD) in accordance with the cultural agreement between Germany and Brazil.

^★: Reprint requests: Ralf Jakobs, MD, Medizinische Klinik C, Klinikum der Stadt Ludwigshafen, Bremserstrasse 79, D-67063 Ludwigshafen, Germany.

^★★: 37/1/91448

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Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms☆,☆☆,★,★★

Abstract

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Am J Surg

Am J Surg

Am J Surg

Issues in cholecystectomy and management of duct stones

Am J Gastroenterol

A multivariate analysis of preoperative risk factors in patients with common bile duct stones

Ann Surg

Do Surgical and endoscopic sphincterotomy prevent or facilitate recurrent common duct stone formation?

Arch Surg

Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder in situ

Gut

Long-term results after endoscopic papillotomy

Endoscopy

Long-term follow-up after sphincterotomy

Endoscopy

Endoscopic sphincterotomy: long-term results in 408 patients with complete follow-up

Endoscopy

Long-term follow-up of patients after endoscopic sphincterotomy for choledocholithiasis

Scand J Gastroenterol

Long-term follow-up after endoscopic management of retained and recurrent common duct stones

Acta Chir Scand

Endoscopic management of common duct stones without cholecystectomy

Br J Surg

Langzeitergebnisse nach endoskopischer Sphinkterotomie bei Patienten mit Gallenblase in situ

Dtsch Med Wschr

Die belassene Steingallenblase—ein Risikofaktor nach endoskopischer Papillotomie?

Z Gastroenterol

Late results of endoscopic sphincterotomy for bile duct stones in elderly patients with gall bladders in situ

Gut

Early and late results of endoscopic sphincterotomy for bile duct stones in patients with “in situ” gallbladder

Endoscopy

Practical statistics for medical research