Do We Need to Trawl at the Time of Stent Removal

Aims: Assess the need for repeating ERCP and balloon trawl at the time of stent removal.

Methods: All consecutive cases of stent removal following laparoscopic cholecystectomy after successful ERCP, done in Yashoda Hospital, Secunderabad, a tertiary care center in Telangana, India, done by routine Endoscopy or ERCP are included in the study. It is an observational study including patients both prospectively and retrospectively from April 2023 till October 2023. The indication for ERCP, timing of Lap. cholecystectomy and the stent removal either by endoscopy or ERCP is analyzed. Any events of stone recurrence at or after stent removal is looked at. Any patient or procedure related factors pertaining to this were also assessed.

Results: Two hundred consecutive patients who underwent stent removal following successful ERCP, stone extraction after laparoscopic cholecystectomy were included in the study. Hundred each were included in the Endoscopic Stent removal and 100 in ERCP, balloon trawl group.

Five patients came back with cholangitis or pain following few days after endoscopic stent removal. The average duration between initial ERCP and the Endoscopic stent removal in this group was 35 days. Whereas in the ERCP group, small stones were noted and cleared on balloon trawl in 15 patients at the time of stent removal. Sludge was noted in another 20 patients. In this group, the mean duration for stent removal was 30 days. Few of them had Cystic duct stones on initial imaging. The plausible explanation for CBD stone after successful ERCP could be slipped out cystic duct stone during cholecystectomy, a retained CBD stone and last is of a new stone formation with longer duration of stent in situ. One patient came back with cholangitis even after ERCP, balloon trawl, and stent removal.

Cost factor analysis showed cheaper strategy in the endoscopic stent removal group as compared to the ERCP group (average Rupees 8,000/- vs. 15,000/-, respectively). Radiation exposure is one additional factor. But if we take the 5 patients versus 1 patient with problems, it was only marginally different. Limitation of our study was the number for comparison is small. Previous studies have documented safety with endoscopic stent removal even after 6 months.^1,2

Conclusions: After successful ERCP, CBD stone extraction, it is reasonable and economical to just remove the stent on Endoscopy. Repeat ERCP, balloon trawl may be considered in a subset of patients with history of cystic duct stone, uncertain clearance and if they comeback for stent removal beyond 6-8 weeks. Literature in this regard has been scarce.

Publication History

Article published online:
22 April 2024