Factors associated with complete clearance of difficult common bile duct stones after temporary biliary stenting followed by a second ERCP: a multicenter, retrospective, cohort study

Abstract

Background Although temporary endoscopic biliary stenting is considered effective for difficult common bile duct (CBD) stones, few studies have investigated the optimal conditions for complete stone clearance at the second endoscopic retrograde cholangiopancreatography (ERCP) after temporary biliary stenting. We aimed to evaluate factors associated with complete clearance.

Methods Patients with difficult CBD stones (a large [≥ 20 mm] or multiple [≥ 3 sized ≥ 15 mm] CBD stones) were retrospectively enrolled from three institutions. Patients who underwent temporary biliary stenting at the first ERCP were analyzed. Double-pigtail plastic stents (7 or 10 Fr) were placed with the proximal ends above the stones. Complete clearance rate and stone size reduction at the second ERCP, and factors associated with complete clearance were evaluated using univariate and multivariate analyses.

Results 85 patients were enrolled (mean age 74.5 years [SD 11.3]; 47 women). Stone size and CBD diameter significantly decreased during the interval. The overall complete stone clearance rate was 64.7 % (55/85) at the second ERCP. The mean stone size reduction was 5.6 mm (SD 6.8). In multivariate analysis, complete clearance rate was significantly lower in male patients, in patients aged > 80 years, and in stones > 25 mm initially, but was significantly higher when 7-Fr stents were placed and stone size was reduced by > 5 mm.

Conclusion Use of 7-Fr rather than 10-Fr plastic stents was beneficial for complete clearance of difficult CBD stones after temporary biliary stenting; older male patients as well as patients with initial stones > 25 mm had a lower clearance rate.

Publication History

Received: 30 September 2019

Accepted: 21 January 2020

Article published online:
27 February 2020

• References

• 1 Lambert ME, Betts CD, Hill J. et al. Endoscopic sphincterotomy: the whole truth. Br J Surg 1991; 78: 473-476
• 2 Sivak Jr. MV. Endoscopic management of bile duct stones. Am J Surg 1989; 158: 228-240
• 3 Vaira D, D’Anna L, Ainley C. et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989; 2: 431-434
• 4 McHenry L, Lehman G. Difficult bile duct stones. Curr Treat Options Gastroenterol 2006; 9: 123-132
• 5 Lee SH, Park JK, Yoon WJ. et al. How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?. Scand J Gastroenterol 2007; 42: 1006-1010
• 6 Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig End 2013; 25: 376-385
• 7 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491
• 8 Chan AC, Ng EK, Chung SC. et al. Common bile duct stones become smaller after endoscopic biliary stenting. Endoscopy 1998; 30: 356-359
• 9 Katsinelos P, Galanis I, Pilpilidis I. et al. The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones. Surg Endosc 2003; 17: 1552-1555
• 10 Horiuchi A, Nakayama Y, Kajiyama M. et al. Biliary stenting in the management of large or multiple common bile duct stones. Gastrointest Endosc 2010; 71: 1200-1203
• 11 Fan Z, Hawes R, Lawrence C. et al. Analysis of plastic stents in the treatment of large common bile duct stones in 45 patients. Dig Endosc 2011; 23: 86-90
• 12 Hong WD, Zhu QH, Huang QK. Endoscopic sphincterotomy plus endoprostheses in the treatment of large or multiple common bile duct stones. Dig Endosc 2011; 23: 240-243
• 13 Lee TH, Han JH, Kim HJ. et al. Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc 2011; 74: 96-102
• 14 Ye X, Huai J, Sun X. Effectiveness and safety of biliary stenting in the management of difficult common bile duct stones in elderly patients. Turk J Gastroenterol 2016; 27: 30-36
• 15 Kwon CI, Kim G, Jeong S. et al. Experimental study on the friction effect of plastic stents for biliary stone fragmentation (with video). Dig Endosc 2018; 30: 107-113
• 16 Kiriyama S, Takada T, Strasberg SM. et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2013; 20: 24-34
• 17 Katsinelos P, Kountouras J, Paroutoglou G. et al. Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones. Dig Liver Dis 2008; 40: 453-459
• 18 Han J, Moon JH, Koo HC. et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. Am J Gastroenterol 2009; 104: 2418-2421
• 19 Katsinelos P, Paroutoglou G, Kountouras J. et al. Efficacy and safety of therapeutic ERCP in patients 90 years of age and older. Gastrointest Endosc 2006; 63: 417-423
• 20 Kim HJ, Choi HS, Park JH. et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc 2007; 66: 1154-1160
• 21 Park JS, Lee DH, Jeong S. et al. Determination of diameter and angulation of the normal common bile duct using multidetector computed tomography. Gut Liver 2009; 3: 306-310
• 22 Di Giorgio P, Manes G, Grimaldi E. et al. Endoscopic plastic stenting for bile duct stones: stent changing on demand or every 3 months. A prospective comparison study. Endoscopy 2013; 45: 1014-1017
• 23 Jain SK, Stein R, Bhuva M. et al. Pigtail stents: an alternative in the treatment of difficult bile duct stones. Gastrointest Endosc 2000; 52: 490-493
• 24 Maxton DG, Tweedle DE, Martin DF. Retained common bile duct stones after endoscopic sphincterotomy: temporary and longterm treatment with biliary stenting. Gut 1995; 36: 446-449
• 25 Hartery K, Lee CS, Doherty GA. et al. Covered self-expanding metal stents for the management of common bile duct stones. Gastrointest Endosc 2017; 85: 181-186
• 26 Cerefice M, Sauer B, Javaid M. et al. Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos). Gastrointest Endosc 2011; 74: 520-526
• 27 Minami A, Fujita R. A new technique for removal of bile duct stones with an expandable metallic stent. Gastrointest Endosc 2003; 57: 945-948
• 28 Karsenti D, Coron E, Vanbiervliet G. et al. Complete endoscopic sphincterotomy with vs. without large-balloon dilation for the removal of large bile duct stones: randomized multicenter study. Endoscopy 2017; 49: 968-976
• 29 Tsuchida K, Iwasaki M, Tsubouchi M. et al. Comparison of the usefulness of endoscopic papillary large-balloon dilation with endoscopic sphincterotomy for large and multiple common bile duct stones. BMC Gastroenterol 2015; 15: 59
• 30 Teoh AY, Cheung FK, Hu B. et al. Randomized trial of endoscopic sphincterotomy with balloon dilation versus endoscopic sphincterotomy alone for removal of bile duct stones. Gastroenterology 2013; 144: 341-345
• 31 Feng Y, Zhu H, Chen X. et al. Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials. J Gastroenterol 2012; 47: 655-663
• 32 Stefanidis G, Viazis N, Pleskow D. et al. Large balloon dilation vs. mechanical lithotripsy for the management of large bile duct stones: a prospective randomized study. Am J Gastroenterol 2011; 106: 278-285
• 33 Korrapati P, Ciolino J, Wani S. et al. The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis. Endosc Int Open 2016; 4: E263-275
• 34 Park YH, Park SJ, Jang JY. et al. Changing patterns of gallstone disease in Korea. World J Surg 2004; 28: 206-210