Retrospective comparative analysis of choledochoscopic bile duct exploration versus ERCP for bile duct stones

Abstract

Debate still exists for the management of choledocholithiasis. The purpose of this study is to quantify the rate of recurrent choledocholithiasis post choledochoscopic bile duct exploration (CBDE) in comparison to ERCP and sphincterotomy, and to demonstrate the feasibility of this approach in a busy metropolitan hospital. Data of patients undergoing CBDE from 2009–2014 at the Northern Hospital, Victoria, Australia, was collected retrospectively. Primary outcomes were bile duct clearance rate and rate of recurrent stones post-clearance. Secondary outcomes measured were post-operative complications, laparoscopic to open conversion rate and operative time. Data of patients undergoing ERCP at the same institution was collected and compared. In total, there were 4,091 cholecystectomy cases performed from 2009–2014, of which 260 (6.3%) of patients had an intraoperative cholangiography (IOC) indicating a common bile duct (CBD) stone. Two hundred and forty-eight patients (95.3%) had a CBDE. The remaining 12 patients (4.6%) had radiological clearance, which were excluded from the study. The overall clearance rate for patients undergoing CBDE was 84% (209/248). The risk of recurrent stones up to 8 years post clearance was 2% (4/209). In the same institution, and between 1998–2012, a total of 1,148 patients underwent ERCP, of which 571 had endoscopic sphincterotomy (ES). Forty-three patients required a repeat ERCP for recurrent CBD stones with a complication rate of 7.5%. Time to recurrence ranged from 6 months to 10 years with a mean of 4.5 years. The rate of recurrence was lower in the CBDE group compared to the patients who had an ERCP (8.9% vs. 2%). CBDE is a feasible and effective method for clearance of CBD stones at the time of laparoscopic cholecystectomy. This approach, although not widely used, reduces the need for ERCP, which has inherent complications. In the longer term, this series showed a significant reduction in the rate of CBD stone recurrence.

Advances in Risk Factors for Recurrence of Common Bile Duct Stones

“…(68) Some retrospective comparative analyses and meta-analyses showed that the rate of recurrence was lower in the LCBDE group compared to the patients who had an EST. (3,63) LC+LCBDE preserve the complete sphincter function of Oddi, which may be associated with the reduction of the recurrence rate of common bile duct stones. A larger sample size should be studied to clarify this conclusion.…”

Exploración de las vías biliares como tratamiento de la litiasis coledociana: manejo laparoscópico vs. convencional. Estudio prospectivo y comparativo

“…Los estudios de Al-Habbal, et al y Al-Temimi et al reportaron una baja incidencia de pacientes que ameritaron CPRE postoperatoria por litiasis residual. (14,17) Pan, et al reportan una tasa de eliminación de litiasis coledociana de 94,1% en el grupo laparoscópico vs. 90,1% en el grupo de CPRE preoperatoria con diferencia estadísticamente significativa. La tasa de litiasis residual fue 1,2 vs 7,9% para los pacientes con exploración laparoscópica de la vía biliar y CPRE preoperatoria respectivamente; resultados estos similares a los obtenidos en el meta-análisis de Zhu et al (9,18) Los resultados de nuestro estudio no lograron demostrar una superioridad evidente del abordaje laparoscópico sobre el convencional, sin embargo no podemos desestimar las ventajas que ofrece la cirugía laparoscopia sobre el abordaje convencional en términos de menor trauma quirúrgico, menor dolor postoperatorio, menor tiempo de hospitalización y una reincorporación más rápida a las actividades habituales del paciente.…”

Impact of single‐stage laparoscopic trans‐cystic exploration on hospital procedures, admissions and length‐of‐stay in common bile duct stone clearance

“…and it has been documented that stone recurrence after ERCP was higher compared with choledoscopic bile duct exploration 16 . Other late sequelae of ERCP include papillary stenosis that may further predispose to cholangitis and pancreatitis 17,18 and post‐sphincterotomy duodenal reflux has also been reported to be a risk factor for cholangiocarcinoma 19,20 . A definite advantage of LTCE is that the sphincter of Oddi is preserved.…”