Risk factors of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones

Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

Laparoscopic cholecystectomy plus common bile duct exploration for extrahepatic bile duct stones and postoperative recurrence-associated risk factors

BACKGROUND

There remain controversies regarding the surgical treatment of extrahepatic bile duct stones (EHBDSs) in clinical practice.

AIM

To explore the curative effect of laparoscopic cholecystectomy (LC) plus common bile duct exploration (CBDE) for the surgical treatment of EHBDSs and to analyze the risk factors that affect postoperative stone recurrence.

METHODS

Eighty-two patients with EHBDSs admitted between March 2017 and March 2023 were selected. Among them, patients treated with open choledocholithotomy plus LC or open cholecystectomy (OC) were set as the control group (n = 40), and those treated with LC plus CBDE served as the observation group (n = 42). The surgical outcomes of the two groups were compared, the surgical complications and Gastrointestinal Quality of Life Index (GIQLI) scores were counted, and the one-year prognostic recurrence was recorded. Independent factors for postoperative recurrence were determined using univariate and multivariate analyses.

RESULTS

The two groups were comparable in the stone residual rate (P > 0.05). The operation time (P < 0.05), intraoperative bleeding (P < 0.05), and total complication rate (P = 0.005) were lower in the observation group than in the control group. The observation group exhibited a marked increase in the GIQLI score, which was higher than the control group (P < 0.05). A lower one-year recurrence rate was determined in the observation group vs the control group (P = 0.027). Sphincter of Oddi dysfunction [odds ratio (OR) = 5.712, P = 0.007] and the treatment scheme of open choledocholithotomy plus LC or OC (OR = 6.771, P = 0.008) were the independent risk factors for one-year recurrence in patients after surgery.

CONCLUSION

LC plus CBDE for patients with EHBDSs can reduce stone residuals, intraoperative bleeding, complications, and postoperative recurrence.

Factors affecting complete stone removal and bile duct stone recurrence in patients with surgically altered anatomy treated by double-balloon endoscopy-assisted endoscopic retrograde cholangiography

OBJECTIVES

This study assessed factors influencing the complete removal and recurrence of bile duct stones in patients with surgically altered anatomy (SAA) undergoing double-balloon endoscopy-assisted endoscopic retrograde cholangiography (DBERC).

METHODS

A retrospective analysis of 289 patients with SAA treated for biliary stones with DBERC at Jichi Medical University Hospital (January 2007 to December 2022) was conducted. Evaluation of factors impacting complete stone removal was performed in 257 patients with successful bile duct cannulation. Logistic and Cox proportional hazards regression models were used to compute the odds ratios (ORs) and hazard ratios (HRs) at 95% confidence intervals (CIs).

RESULTS

Of 257 patients, 139 (54.0%) and 209 (81.3%) achieved initial and complete removal, respectively. Recurrence occurred in 55 (21.4%) patients. Factors associated with initial complete stone removal included cholangitis (P < 0.01, OR 0.48, 95% CI 0.27-0.83), number of stones (P < 0.01, OR 0.31, 95% CI 0.18-0.54), and largest stone diameter (P < 0.01, OR 0.37, 95% CI 0.20-0.67). The size of the largest stone was associated with complete removal (P = 0.01, OR 0.24, 95% CI 0.13-0.76). Recurrence was associated with cholangitis (P = 0.046, HR 0.54, 95% CI 0.29-0.99), congenital biliary dilatation (P = 0.01, HR 2.65, 95% CI 1.21-5.80), and number of stones (P = 0.02, HR 1.96, 95% CI 1.12-3.41).

CONCLUSIONS

Successful complete bile stone removal in patients with SAA depends on the stone diameter and number. Stone recurrence is influenced by the number of stones and history of congenital biliary dilatation.

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review

Background

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow-up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those.

Methods

A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors.

Results

A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2-13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in-situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement.

Conclusion

Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow-up in high-risk patients.

Recurrence of common bile duct stones after endoscopic clearance and its predictors: A systematic review

Background

The primary therapeutic strategy for the management of bile duct stones (BDS) is endoscopic retrograde cholangiopancreatography. However, there may be a recurrence of BDS on follow‐up. Multiple risk factors have been studied for the prediction of BDS recurrence. We aimed to analyze the incidence of symptomatic BDS recurrence, systematically review the risk factors, and analyze the most important risk factors among those.

Methods

A comprehensive search of three databases was conducted from inception to November 2022 for studies reporting the recurrence of BDS recurrence after endoscopic retrograde cholangiopancreatography with clearance, along with an analysis of risk factors.

Results

A total of 37 studies with 12,952 patients were included in the final analysis. The pooled event rate for the recurrence of BDS stones was 12.6% (95% confidence interval: 11.2–13.9). The most important risk factor was a bile duct diameter ≥15 mm, which had a significant association with recurrence in twelve studies. Other risk factors with significant association with recurrence in three or more studies were the reduced angulation of the bile duct, the presence of periampullary diverticulum, type I periampullary diverticulum, in‐situ gallbladder with stones, cholecystectomy, multiple stones in the bile duct, use of mechanical lithotripsy, and bile duct stent placement.

Conclusion

Around one out of seven patients have BDS recurrence after the initial endoscopic retrograde cholangiopancreatography. Bile duct size and anatomy are the most important predictors of recurrence. The assessment of risk factors associated with recurrence may help keep a close follow‐up in high‐risk patients.

Primary choledocholithiasis occurrence and recurrence is synergetcally modulated by the bile microbiome and metabolome alternations

AIMS

Primary choledocholithiasis is a common digestive disease with high morbidity and relapse. However, the compositions and functions of the bile microbial ecosystem and the pathogenesis of microfloral regulation of host metabolism resulting in stone formation are poorly understood.

MAIN METHODS

Biliary samples collected from patients with acute cholangitis induced by benign biliary stricture (nonlithiasis group, n = 17) and primary choledocholithiasis (lithiasis group, n = 33) were subjected to multiomics analyses. Furthermore, clinicopathological features collected over a 24-month follow-up period were examined to evaluate the predictive value of candidate microbes.

KEY FINDINGS

Five alpha diversity indices of the bile microbiome were significantly decreased in the lithiasis group. Furthermore, we identified 49 differential bile flora between the two groups, and the relative abundances of 6 bacteria, Actinobacteria, Actinobacteriota, Staphylococcales, Micrococcales, Altererythrobacter and Carnobacteriaceae, were associated with primary choledocholithiasis relapse conditions. Multiomics analyses showed that specific changes in disease-related bacterial taxa were closely related to metabolite variation (low-molecular weight carboxylic acids, sterol liquid and acylcarnitine), which might reflect disease prognosis. According to microbiomic and metabolomic pathway analyses, we revealed that bacterial infections, microbiota-derived amino acid metabolites and secondary bile acid-related pathways were significantly enriched in the stone-formation group, suggesting a novel host-microbial metabolic mechanism of primary choledocholithiasis.

SIGNIFICANCE

Our study first indicates bile host-microbial dysbiosis modulates the abnormal accumulation of metabolites might further disrupt calcium homeostasis and generate insoluble saponification. Additionally, we determined the predictive value of Actinomycetes phylum reduction for recurrence in primary common bile duct stone patients.

Predicting the Recurrence of Common Bile Duct Stones After ERCP Treatment with Automated Machine Learning Algorithms

BACKGROUND

Recurrence of common bile duct stones (CBDs) commonly happens after endoscopic retrograde cholangiopancreatography (ERCP). The clinical prediction models for the recurrence of CBDs after ERCP are lacking.

AIMS

We aim to develop high-performance prediction models for the recurrence of CBDS after ERCP treatment using automated machine learning (AutoML) and to assess the AutoML models versus the traditional regression models.

METHODS

473 patients with CBDs undergoing ERCP were recruited in the single-center retrospective cohort study. Samples were divided into Training Set (65%) and Validation Set (35%) randomly. Three modeling approaches, including fully automated machine learning (Fully automated), semi-automated machine learning (Semi-automated), and traditional regression were applied to fit prediction models. Models' discrimination, calibration, and clinical benefits were examined. The Shapley additive explanations (SHAP), partial dependence plot (PDP), and SHAP local explanation (SHAPLE) were proposed for the interpretation of the best model.

RESULTS

The area under roc curve (AUROC) of semi-automated gradient boost machine (GBM) model was 0.749 in Validation Set, better than the other fully/semi-automated models and the traditional regression models (highest AUROC = 0.736). The calibration and clinical application of AutoML models were adequate. Through the SHAP-PDP-SHAPLE pipeline, the roles of key variables of the semi-automated GBM model were visualized. Lastly, the best model was deployed online for clinical practitioners.

CONCLUSION

The GBM model based on semi-AutoML is an optimal model to predict the recurrence of CBDs after ERCP treatment. In comparison with traditional regressions, AutoML algorithms present significant strengths in modeling, which show promise in future clinical practices.

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial

Background

Mechanical lithotripsy produces stone fragments that are not easily detected by cholangiography and is a potential cause of recurrence of common bile duct stones (CBDS). This study aims to clarify whether 100 ml saline irrigation after mechanical lithotripsy reduces the recurrent rate of CBDS.

Methods

In this randomized controlled trial performed at the Surgical Endoscopy Center, the First Hospital of Lanzhou University between May 10, 2019, and Dec 31, 2020, patients undergoing endoscopic mechanical lithotripsy were randomly assigned to receive saline irrigation (study group) or no irrigation (control group). The saline irrigation was given 100 ml saline pulse irrigation after cholangiography showed no residual stones. Patients were followed up for at least 24 months after endoscopic stone removal to assess the recurrence of CBDS. This study was registered with ClinicalTrials.gov (NCT03937037).

Findings

During the median follow-up period of 35.6 months (interquartile range, 26.0-40.7), 43 of the 180 patients had stone recurrence (24%). The frequency of recurrence of CBD stones was 12.22% in the saline irrigation group and 35.56% in the control group, with a difference of 23.33% between the two groups (95% confidence interval [CI], 11.35%-35.32%, p < 0.001). Multivariable Cox proportional hazards analyses showed that constipation (hazard risk [HR] 2.42; 95% CI, 1.22-4.80, p = 0.012), periampullary diverticulum (PAD) (HR 3.06; 95% CI, 1.62-5.79, p < 0.001), and total to direct bilirubin ratio (HR 1.48; 95% CI, 1.21-1.81, p < 0.001) were independent risk factors for the recurrence of CBDS. Saline irrigation was the only preventive factor for the recurrence of CBDS (HR 0.22; 95% CI, 0.11-0.44, p < 0.001).

Interpretation

For patients with CBDS requiring mechanical lithotripsy, 100 ml saline irrigation effectively reduces the recurrent rate of CBDS after endoscopic stone removal.

Funding

This work was supported by National Natural Science Foundation of China (32160255); Natural Science Foundation of Gansu Province (22JR5RA898, 20JR10RA676); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043).

Comparison of Repeated Recurrence of Common Bile Duct Stones and Occurrence of Hepatolithiasis After Synchronous Laparoscopic Cholecystectomy Combined with Laparoscopic Common Bile Duct Exploration or with Endoscopic Sphincterotomy: a 10-Year Retrospective Study

BACKGROUND

The optimal treatment options for gallstones together with common bile duct stones (CBDS) remain controversial. The aim of this study was to further compare the recurrence rate of stones after synchronous laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (SLCL) and synchronous laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy (SLCE) and to determine which option is more effective in reducing the rate of repeated recurrence of CBDS and the incidence rate of hepatolithiasis.

METHODS

We retrospectively investigated the clinical data of patients who underwent SLCL or SLCE at our hepatobiliary center between August 2012 and August 2020. The primary and secondary endpoints of this study were the recurrence of CBDS and the occurrence of hepatolithiasis, respectively.

RESULTS

In total, 1005 patients were enrolled in this study, including 431 patients in the SLCL group and 574 patients in the SLCE group. SLCL was associated with a significantly decreased rate of CBDS recurrence (4.18% vs. 7.84%, P = 0.018), repeated CBDS recurrence (0.70% vs. 3.00%, P = 0.010), and incidence of hepatolithiasis (0.00% vs. 1.05%, P = 0.040). Compared with SLCE, SLCL was an independent protective predictor of the recurrence of CBDS (relative risk, 0.505; 95% confidence interval, 0.286-0.891; P = 0.018) and repeated recurrence of CBDS (relative risk, 0.226; 95% confidence interval, 0.066-0.777; P = 0.018).

CONCLUSIONS

SLCL is an optimal treatment option to SLCE for patients with gallstones combined with CBDS.

Comparing Stone Recurrence Following Surgical Common Bile Duct Exploration or Endoscopic Stone Extraction for Patients with Common Bile Duct Stones

Background: Laparoscopic common bile duct exploration (LCBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are two methods of retrieving common bile duct (CBD) stones. Aspects of CBD stone management, such as sphincterotomy, have been implicated as risks for CBD stone recurrence although evidence is weak. The aim of this study was to compare stone recurrence following LCBDE and/or ERCP. Methods: Data were collected retrospectively for patients undergoing LCBDE and/or ERCP for CBD stones at a single center from 2008 to 2018. Primary outcome was stone recurrence (>6 months after duct clearance). Risk factors for recurrence were assessed using univariate and multivariate analyses. Results: A total of 445 patients underwent LCBDE-only, 79 patients underwent ERCP-only and 80 patients underwent LCBDE-ERCP. LCBDE-only patients were younger and preoperatively less morbid than ERCP-only patients. Although there was no significant difference for recurrence, there was a trend toward higher recurrence with ERCP-only compared with LCBDE-only and LCBDE-ERCP (5.1% versus 2.0% and 2.5%, P = .280). On univariate comparison, patients with a recurrence were significantly older, had a higher admission white cell count, higher number of ERCPs, increased transampullary stent use, and higher maximum CBD diameter. Total number of ERCP was the only independent predictor of stone recurrence (odds ratio 6.85 [2.55-18.42], P < .001) following multivariate regression. Conclusion: Management plan was not associated with stone recurrence. The total number of ERCP was the only independent predictor of recurrence. Within the limitations of case selection and bias toward LCBDE, this study suggests that limiting repeated ERCP may reduce CBD stone recurrence.

Primary Recurrent Common Bile Duct Stones: Timing of Surgical Intervention

Cholelithiasis (gallstones) is a very common medical problem worldwide, with 5-30% of patients demonstrating a combined condition of cholelithiasis and choledocholithiasis (common bile duct stones (CBDS)). CBDS are usually classified as primary or secondary stones. Primary CBDS are defined as stones detected 2 years or more following cholecystectomy, while secondary stones, the most common type, usually migrate from the gallbladder to the bile ducts. Recurrent CBDS are defined as stones detected 6 months or more following endoscopic retrograde cholangiopancreatography (ERCP) with complete duct clearance. Although ERCP with endoscopic sphincterotomy has emerged as the main therapeutic option for CBDS, with up to 95% bile duct clearance rate, up to 25% of said patients develop recurrent bile duct stones. Thus far, several issues related to recurrent CBDS are still unclear and questions regarding this specific pathology have no precise answers: how many trials of ERCP and endoscopic sphincterotomy should be attempted before referring the patient for surgical management? Is there an association between risk factors and early surgical intervention? Thus, currently, there is no worldwide scientific-based consensus regarding the best management of this specific group of patients. The main issue for this article is to review the relevant English literature and find out the main high risk factors for recurrent CBDS, and form a diagnostic and treatment plan, hence, identifying the subgroup of patients that will benefit from early surgical management, preventing further ERCP-associated complications.

Cost-effective analysis of preliminary single-operator cholangioscopy for management of difficult biliary stones

Background and study aims  Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods  A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results  First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions  Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.

Patients with Primary and Secondary Bile Duct Stones Harbor Distinct Biliary Microbial Composition and Metabolic Potential

Introduction

Cholelithiasis has a high incidence worldwide and limited treatment options due to its poorly understood pathogenesis. Furthermore, the role of biliary microbiota in cholelithiasis remains understudied. To address these questions, we performed microbial sequencing from biliary samples from primary bile duct stone (PBDS) and secondary bile duct stone (SBDS) patients.

Results

We analyzed in total 45 biliary samples, including those from cholelithiasis patients with PBDS or SBDS and people with other digestive diseases. 16S rRNA sequencing showed the bacteria family Alcaligenaceae increased in relative abundance in the lithiasis group compared with the non-lithiasis group. In addition, the PBDS group showed significantly lower bacterial diversity than SBDS, with Propionibacteriaceae, Sphingomonadaceae, and Lactobacillaceae as the most significant bacteria families decreased in relative abundance. We further performed whole metagenomic shotgun sequencing (wMGS) and found increased ability of biofilm synthesis and the ability to sense external stimuli in PBDS based on functional annotation of mapped reads. From genome-resolved analysis of the samples, we identified 36 high-quality draft bacterial genome sequences with completion ≥70% and contamination ≤10%. Most of these genomes were classified into Proteobacteria, Firmicutes, or Actinobacteria.

Conclusions

Our findings indicated that there is a subtle impact on biliary microbiome from cholelithiasis while the difference is more pronounced between the PBDS and SBDS. It was revealed that the diversity of biliary microbiota in PBDS is lower, while some metabolic pathways are up-regulated, including those linked to higher incidence of different types of cancer, providing new insights for the understanding of cholelithiasis with different origin.

Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study

BACKGROUND

Recurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone.

METHODS

We performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone.

RESULTS

In univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69-55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05-318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00-1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19-0.81, P = 0.012) was a protective factor.

CONCLUSIONS

We identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.

Diabetes mellitus is associated with a higher rate of acute cholangitis among patients with common bile duct stones: A retrospective study

Common bile duct (CBD) stone is a commonly encountered disease that is associated with various clinical presentations ranging from the mild form of biliary colic to the severe complication of acute cholangitis. Recently, diabetes mellitus (DM) has been linked to the development of biliary diseases; however, no data regarding the association of DM with acute cholangitis development in the setting of CBD stone exist. The aim of the current study was to investigate whether DM represents a risk factor for acute cholangitis in patients with CBD stone. We performed a retrospective cross-sectional study from January 1, 2010 till June 1, 2020 of all patients presenting to Galilee Medical Center with various clinical presentations of documented CBD stone, including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 687 patients were included in the final analysis. Among them, 101 patients (14.7%) had CBD stone associated with acute cholangitis (group A), as compared to 586 patients (85.3%) without acute cholangitis (group B). The average ages in groups A and B were 77.7 ± 13.6 and 62.5 ± 20.5 years, respectively (P < .0001). The prevalence of DM was significantly higher in group A as compared to group B (52.5% vs 36.3%, P = .001). On univariate analysis, age (odds ratio [OR] 1.05, P < .0001), male gender (OR 1.54, P = .04), and DM (OR 1.92, P = .002) were associated with acute cholangitis development, and on multivariate logistic regression analysis, the correlation was preserved for DM (OR 1.93, 95% confidence interval 1.26-2.96, P = .002). DM showed a significant association with acute cholangitis development among patients with CBD stone. Identification of bile duct stones in diabetic patients is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications.

Reinterventions following laparoscopic cholecystectomy and bile duct exploration. A review of prospective data from 5740 patients

Background

Complications following laparoscopic cholecystectomy (LC) and common bile duct exploration (CBDE) for the management of gallstones or choledocholithiasis impact negatively on patients’ quality of life and may lead to reinterventions. This study aims to evaluate the causes and types of reintervention following index admission LC with or without CBDE.

Methods

A prospectively maintained database of LC and CBDE performed by a single surgeon was analysed. Preoperative factors, difficulty grading and perioperative complications requiring reintervention and readmissions were examined.

Results

Reinterventions were required in 112 of 5740 patients (2.0%), 89 (1.6%) being subsequent to complications. The reintervention cohort had a median age of 64 years, were more likely to be females (p < 0.0023) and to be emergency admissions (67.9%, p < 0.00001) with obstructive jaundice (35.7%, p < 0.00001). 46.4% of the reintervention cohort had a LC operative difficulty grade IV or V and 65.2% underwent a CBDE. Open conversion was predictive of the potential for reintervention (p < 0.00001). The most common single cause of reintervention was retained stones (0.5%) requiring ERCP followed by bile leakage (0.3%) requiring percutaneous drainage, ERCP and relaparoscopy. Relaparoscopy was necessary in 17 patients and open surgery in 13, 6 of whom not resulting from complications. There were 5 deaths.

Conclusion

This large series had a low incidence of reinterventions resulting from complications in spite of a high workload of index admission surgery for biliary emergencies and bile duct stones. Surgical or endoscopic reinterventions following LC alone occurred in only 0.8%. The most common form of reintervention was ERCP for retained CBD stones. This important outcome parameter of laparoscopic biliary surgery can be optimised through early diagnosis and timely reintervention for complications.