Risk factors and management of primary choledocholithiasis: a systematic review

Abstract

Background Primary choledocholithiasis (PC) is a common disease in biliary surgery. The treatment is always challenging due to its high recurrence. A systemic review is undertaken to determine the risk factors for recurrence and provide with the individualized management strategy. Methods Electronic databases PubMed (Medline), Embase and Cochrane Central Register of Controlled Studies were searched for relevant articles on risk factors for PC recurrence. Its therapeutic intervention was also collected and analysed. Results A total of 36 articles were eligible for inclusion. The recurrent risk factors include abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dilation, sharp angulation and stone number), metabolism (advanced age and hypothyroidism) and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually induce cholestasis and stone formation. At present, there is no guideline and expertise consensus for PC management. The treatment mainly consists of stone retrieval approaches and internal drainage surgeries. The former are minimally invasive methods: endoscopic sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and choledochojejunostomy (CJS) with Roux‐en‐Y reconstruction. By far, the internal drainage surgeries have significantly lower recurrence than stone retrieval approaches. Conclusion Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment. For recurrent PC, CDS is more suitable to the elderly, while Roux‐en‐Y CJS reserves for young patients or those in good conditions.

Causes and surgical management of choledocholithiasis after cholecystectomy

“…In addition, bile cultures were positive in approximately 91% of the 86 patients. These results are consistent with studies of primary choledocholithiasis [5,23], and indicate that bacterial infection and cholestasis secondary to abnormal structure and dysfunction of the Oddis sphincter are the main cause of choledocholithiasis after cholecystectomy.…”

A nomogram for predicting stones recurrence in patients with bile duct stones undergoing laparoscopic common bile duct exploration

“…Although the present study showed no correlation between the CBD diameter and the recurrence of bile duct stones after LCBDE, several previous studies have confirmed it 8,28,29 . In addition, the presence of parapapillary diverticulum tends to accumulate bacteria and metabolic material, such as shedding mucosal cells, which then leads to infection and chronic inflammation and stimulates the Oddi's sphincter, which results in the blockage of the duodenal papilla and the inability to drain bile smoothly 30–32 …”

“…8,28,29 In addition, the presence of parapapillary diverticulum tends to accumulate bacteria and metabolic material, such as shedding mucosal cells, which then leads to infection and chronic inflammation and stimulates the Oddi's sphincter, which results in the blockage of the duodenal papilla and the inability to drain bile smoothly. [30][31][32] Several previous studies have confirmed that metabolic abnormalities represented by hyperlipidemia, choledocholithiasis, obesity, non-alcoholic fatty liver disease, diabetes, and insulin resistance are important risk factors that promote the development of choledocholithiasis. [33][34][35] Here, we demonstrated that fatty liver was an independent risk factor in the recurrence of bile duct stones after LCBDE, which is consistent with the previous studies.…”

“… 8 , 28 , 29 In addition, the presence of parapapillary diverticulum tends to accumulate bacteria and metabolic material, such as shedding mucosal cells, which then leads to infection and chronic inflammation and stimulates the Oddi's sphincter, which results in the blockage of the duodenal papilla and the inability to drain bile smoothly. 30 , 31 , 32 …”

Luces y sombras en la predicción de coledocolitiasis: oportunidades para la investigación futura

“…Por otra parte, la información y su uso en coledocolitiasis primaria es limitada. Algunos modelos en coledocolitiasis secundaria se han adaptado al abordaje de la coledocolitiasis primaria, pero su rendimiento es subóptimo al tratarse de entidades con una vía fisiopatológica diferente con alta tasa de recurrencia (hasta un 41,7 %) (36) .…”