Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases

Abstract

Background: Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST. Methods: A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years. Results: A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%). Conclusions: Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Endoscopic Biliary Large Balloon Dilation Lithotripsy for Giant and Impacted Stones Removal: A Western Series

“…Giant stones, particularly those larger than 2 cm, require fragmentation before retrieval, even in cases in which the bile duct was previously large balloon dilated, in order to avoid stone impaction at the distal bile duct [2, 4]. Mechanical lithotripsy is the most practical and used method for such cases [1, 2, 4], with a success rate of about 80–90% and a small increase in the complication rate in comparison to standard stone extraction [1, 2, 4]. However, the successfulness of mechanical lithotripsy depends on the capacity of the basket to enclose the stone.…”

“…Endoscopic papillotomy (EPT) with stone extraction by balloon and/or basket is the chief method for managing bile duct stones [1]. Nevertheless, in 10–20% of the patients with choledocholithiasis, stone retrieval is not amenable with standard techniques [2, 3].…”

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

“…Endoscopic sphincterotomy with stone extraction by balloon and/or basket is the method of choice for treating bile duct stones[ 1 ]. However, in patients with difficult bile duct stones (impacted, multiple or > 1 cm, or having a tapered distal duct), additional methods such as mechanical lithotripsy, intracorporeal lithotripsy, or papillary large balloon dilation are needed.…”

Increased Risk of Pyogenic Liver Abscess after Endoscopic Sphincterotomy for Treatment of Choledocholithiasis

“…The short-term complications include procedural bleeding, pancreatitis, cholangitis, and perforation, whose overall incidence ranges from 2.5-13.1%. [3][4][5][6][7] As for longterm complications, Oliveira-Cunha et al 8 reported the incidence of cholangiocarcinoma varied from 0-3.1% between studies, the rate of recurrent choledocholithiasis from 3.2-22.3%, and low incidence of cholangitis in the absence of recurrent biliary stones.…”