Retrospective Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2025; 17(7): 106712
Published online Jul 27, 2025. doi: 10.4240/wjgs.v17.i7.106712
Ice-breaking sign: A radiological sign influencing the treatment strategies for choledocholithiasis
Xiao-Yu Zhao, Ming Chen, Gang Wang, Long Cui, Zhi Xu, Chun-Sheng Hou, Li-Xin Wang, Ling-Fu Zhang, Xiao-Feng Ling
Xiao-Yu Zhao, Gang Wang, Long Cui, Zhi Xu, Chun-Sheng Hou, Li-Xin Wang, Ling-Fu Zhang, Xiao-Feng Ling, Department of General Surgery, Peking University Third Hospital, Beijing 100191, China
Ming Chen, Department of Radiology, Peking University Third Hospital, Beijing 100191, China
Co-first authors: Xiao-Yu Zhao and Ming Chen.
Co-corresponding authors: Ling-Fu Zhang and Xiao-Feng Ling.
Author contributions: Zhao XY performed data collection and statistical analysis; Zhao XY and Chen M drafted the manuscript, they contributed equally to this article, they are the co-first authors of this manuscript; Zhao XY and Chen M, Zhang LF, and Ling XF designed the research study; Wang G, Cui L, Xu Z, Hou CS and Wang LX contributed to the review and revision of the manuscript; Zhang LF and Ling XF contributed equally to this article, they are the co-corresponding authors of this manuscript; and all authors thoroughly reviewed and endorsed the final manuscript.
Supported by Clinical Cohort Construction Program of Peking University Third Hospital, No. BYSYDL2023005; and Peking University Third Hospital Innovation Transformation Fund, No. BYSYZHZB2023105.
Institutional review board statement: This study was approved by the Medical Ethics Committee of Peking University Third Hospital, approval No. IRB00006761-M2022592.
Informed consent statement: Informed consent for data sharing was not obtained from the participants but the presented data are anonymized and risk of identification is low.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at xiaofengling@bjmu.edu.cn. Informed consent for data sharing was not obtained from the participants but the presented data are anonymized and risk of identification is low.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Xiao-Feng Ling, MD, PhD, Professor, Department of General Surgery, Peking University Third Hospital, No. 49 Huayuan North Road, Beijing 100191, China. xiaofengling@bjmu.edu.cn
Received: March 6, 2025
Revised: April 17, 2025
Accepted: May 20, 2025
Published online: July 27, 2025
Processing time: 140 Days and 19.2 Hours
Abstract
BACKGROUND

Choledocholithiasis is a common benign disease of the biliary tract. We identified a particular type of choledocholithiasis characterized by sudden narrowing of the common bile duct at the site of impaction, which caused a marked increase in surgical difficulty and risk compared to treatment for typical choledocholithiasis. This phenomenon has not been described in previous studies.

AIM

To propose the ice-breaking sign and evaluate its influence on treatment strategies for choledocholithiasis.

METHODS

Using a retrospective case-control study design, patients who were diagnosed with common bile duct stones and admitted to the Emergency Department of Peking University Third Hospital between January 2018 and December 2023 were included. Propensity score matching was used to match cases and controls. Univariate analysis was conducted to assess the differences in clinical data between the two groups of patients.

RESULTS

There were no significant differences in the baseline data between the two groups, except for higher incidence of jaundice, alkaline phosphatase and total bilirubin in the ice-breaking sign group. Compared to the control group, the ice-breaking sign group had lower success rates for endoscopic retrograde cholangiopancreatography (25.0% vs 81.8%, P = 0.006) and laparoscopic common bile duct exploration (69.4% vs 93.8%, P = 0.007), longer operation time (148.04 ± 60.55 minutes vs 106.15 ± 35.21 minutes, P = 0.001), higher likelihood of T-tube placement (62.2% vs 31.3%, P = 0.016) and using lithotripsy techniques during surgery (29.7% vs 0%, P = 0.001), more intraoperative bleeding [25.0 (20.0-50.0) mL vs 10.0 (10.0-20.0) mL, P < 0.001] and longer postoperative hospital stay [6.50 (5.0-9.0) days vs 5.50 (3.0-6.50) days, P = 0.002]. The ice-breaking sign group showed significantly more dilatation in the proximal than distal bile duct.

CONCLUSION

The ice-breaking sign, a newly identified radiological phenomenon, may influence therapeutic decisions in choledocholithiasis, suggesting laparoscopic common bile duct exploration as the preferred approach over endoscopic retrograde cholangiopancreatography in patients exhibiting this sign.

Keywords: Choledocholithiasis; Surgical approach; Difficult common bile duct stones; Endoscopic management; Laparoscopic management

Core Tip: This study identified the ice-breaking sign, a novel radiological marker on magnetic resonance cholangiopancreatography, characterized by abrupt distal common bile duct narrowing with proximal dilation in choledocholithiasis. Patients with this sign exhibited markedly lower success rates for endoscopic retrograde cholangiopancreatography (25.0% vs 81.8%) and laparoscopic common bile duct exploration (69.4% vs 93.8%), necessitating advanced techniques like lithotripsy. The sign indicates higher surgical complexity and underscores laparoscopic common bile duct exploration as the preferred approach over endoscopic retrograde cholangiopancreatography. Preoperative recognition aids in risk stratification, optimizing treatment strategies for challenging bile duct stones.