Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

Table 1 Number and percentage of patients who experienced one or more (up to five) symptomatic recurrences

No. of recurrences	Patients (n = 67) n (%)
1	45 (67.1)
2	16 (23.8)
3	4 (5.9)
4	1 (1.5)
5	1 (1.5)

Most of the patients experienced only a single episode (67%).

Table 2 Number and percentage of endoscopic retrograde cholangiopancreatography required to treat patients with recurrence

No. of ERCP sessions	Patients (n = 67) n (%)
2	31 (46)
3	16 (23.8)
4	13 (19)
5	5 (7.46)
6	2 (2.98)

ERCP: Endoscopic retrograde cholangiopancreatography.

Table 3 Baseline characteristics of the study groups

Variable	Recurrence group (n = 67)	Control group (n = 67)	P value
Age, yr	71.2 ± 12.4	71.9 ± 12.6	0.82
Sex, male	26/67	28/67	0.86
History of cholecystectomy before first ERCP	37	40	0.73
BEA/gastric surgery	4	2	0.68
	(2 billroth, 2 BEA)	(1 billroth, 1 BEA)
Mean follow-up time, mo	70,1 ± 31.7	68.5 ± 36.1	0.8
	(2-121)	(1-129)

Recurrence group: Patients with a history of recurrent common bile duct stones; Control group: Patients with a history of non recurrent common bile duct stones; BEA: Biliary enteric anastomosis.

Table 4 Parameters of the first endoscopic retrograde cholangiopancreatography/risk factors for recurrence in patients with or without a history of recurrent common bile duct stones

Variable	Recurrence group (n = 67)	Control group (n = 67)	P value
Stone size, mm	11.0 ± 7.0	7.5 ± 4.5	0.007
Stone number, n	4.9 ± 4.4	4.3 ± 4.7	0.53
CBD diameter, mm	16.03 ± 6.1	12.0 ± 4.6	0.001
CBD angulation method 1 (accumulative score)	303.97 ± 34.41	304.84 ± 31.61	0.91
CBD angulation method 2 (minimal angle score)	137.03 ± 17.0	138.41 ± 14.18	0.71
Difficult bile duct stones	24	14	0.04
Use of mechanical lithotripsy	13	5	0.04
No. of ERCP sessions required to clear the bile duct	1.33 ± 0.6	1.34 ± 0.7	0.95
More than one ERCP needed to clear the bile duct initially	14	11	0.43
Gallbladder in situ	2	5	1
Periampullary diverticula	25	16	0.066

Gallbladder in situ (remaining gallbladder): Patients who did not/could not conform to the instructions to perform cholocystectomy after the first ERCP, or a cholocystectomy was not indicated. ERCP: Endoscopic retrograde cholangiopancreatography; CBD: Common bile duct.

Table 5 Risk factors for recurrence of choledocholithiasis proposed in the literature

Proposed risk factor	Ref.	Comment section
DBR	[19-21]	DBR
Pneumobilia	[19]	Indicative of DBR
Acute distal CBD angulation	[19]	Promotes bile stasis
CBD dilation	[19]	Promotes bile stasis
Periampullary diverticulum	[19]	Promotes bile stasis
Prior EST	[22,23]	Promotes DBR
Intact gallbladder with stones in situ	[22]	(Secondary) stone CBD migration
Billiary stricture	[22]	Promotes bile stasis
Papillary stenosis	[22]	Promotes bile stasis
ML	[22]	Small residual microlithiasis acts as nidi for stone formation
Stone size	[24]	Size of the largest stone
Cirrhosis	[22]	Delayed biliary emptying/bile stasis
Delayed biliary emptying	[22]	Promotes bile stasis
Bacterial infection/colonization of the CBD. Bacterial count	[25,26]	Promotes chronic infection, and inflammation, promotes stone formating
Impaired biliary flow	[25]	Scintigraphic study
Cholecystectomy (without stones)	[27]	Impede flushing of nidus/residual stones
Post-procedural sphincter function impaired	[6,27]	EST vs EPBD/EPLBD vs EPSBD, promote DBR
Number of sessions to clear duct at first presentation	[6]	# of ERCPs required to achieve a patent CBD
Age	[6]	Old age
Previous cholecystectomy (open or lap)	[6]
Serum lvls of chol	[24]	Lithogenic properties
EST size	[24]	Minimal size is protective
Inflammation CBD	[24]
Parasites of the CBD	[24]	Parasitic infection
Foreign bodies in the CBD	[24]
Concurrent cholecystolithiasis and cholelithiasis	[28]
Post stone removal CBD diameter	[21]	At 72 h after stones removal, cholangiogram via nasobiliary tube
EPLBD > 10 mm	[29]	Disruption of SO, DBR
Variations of the ABCB4, ABCB11 genes	[30]	Affect composition of bile. Associated with cholestasis, cholelithiasis and formation of primary intrahepatic stones
Excessive dilation of the CBD	[31]	Recurrence rate was 40% when maximum CBD diameter was more than 20 mm, whereas recurrence rate was 18% when maximum CBD diameter was 20 mm or less

The level of evidence varies. DBR: Duodenal-biliary reflux; CBD: Common bile duct; EST: Endoscopic sphincterotomy; ML: Mechanical lithotripsy; EPBD: Endoscopic papillary balloon dilation; EPLBD: Endoscopic papillary large balloon dilation; EPSBD: Endoscopic papillary small balloon dilation; ERCP: Endoscopic retrograde cholangiopancreatography; Llv: Level; Chol: Cholesterol; SO: Sphincter of Oddi.