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Original Article
Endoscopic management of multiple and large choledochal
stones:
success and complication rates and associated factors Hassan
Seddik1, Tarik Adioui1, Hanane Massit1, Hanane Basr1, Brahim
Aitbihi1, Rachid Akka2, Ahmed Benkirane1
ABSTRACT Background: Residual lithiasis of common bile duct is
an indication of choice for
endoscopic sphincterotomy. Endoscopic treatment provides
clearance of the common
bile duct in 90% of cases. However, the presence of multiple or
large stones may limit
its results. The aim of this study is to evaluate success rate,
associated factors and
complications of endoscopic treatment in this condition.
Material and methods: A total of 542 patients who had undergone
endoscopic
retrograde cholangiopancreatography for common bile duct stones
from January 2007
to March 2013 were retrospectively studied. We compared the
results and
complications in patients with multiple and/or large stones
(group I) versus patients
with simple choledochal lithiasis (group II).
Results: Patients with multiple and/or large stones represented
32.8% of all patients.
The Success rate after first catheterization was 64% in group I
versus 90.2% in group II
(p
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and the diameter of the CBD were obtained on
cholangiography.
The size (maximal transverse diameter) of stones and the
caliber
of the CBD were measured, taking as reference the diameter
of
duodenoscope. In cases of unsuccessful stone extraction
using
balloon or Dormia basket, additional maneuvers were
undertaken as appropriate: mechanical lithotripsy,
extracorporeal shock wave lithotripsy, or sphincteroclasia.
Nasobiliary tube was placed temporarily in cases of
incomplete
common bile duct endoscopic clearance, purulent cholangitis,
or
complications such as papillae bleeding. ERCP with a further
attempt at CBD clearance was performed within 3-7 days. If
the
stone could not be extracted, surgery (open exploration of
CBD)
was proposed. Plastic stents were placed for patients
presenting
contraindication for surgery. Endoscopes and instruments
used
were: Olympus JF-V260 and duodenoscopes Olympus TJF-240;
sphincterotome triple lumen (Tri-tome®_ Cook® TRI-25);
guidewire (Metro® 35-480- Cook®) Dormia basket (The Web®
Extraction Trainers - Cook®) balloon extraction (Tri-Ex®-
Cook®) lithotripter (Soehendra® -COOK®) Balloon dilation
(14-16 Eclipse® - Cook®) naso-biliary drain (ENBD Cook®-7)
and plastic stents (ST-2 Soehendra ® Tannenbaum ®- Cook®).
The complete clearance of CBD was defined as success.
Overall
success included success after additional maneuvers and/or
re-
intervention. The occurrence of early complications was
noted:
acute pancreatitis, perforation, papillae bleeding and
cholangitis.
STATISTICAL ANALYSIS
Data were analyzed using SPSS 13 software (Statistical
Package
for Social Sciences). Quantitative variables were expressed
as
mean ± standard deviation and analyzed using the Student t
test,
categorical variables were expressed in percentages and
numbers and analyzed using the chi-square test. Factors
associated with overall success of endoscopic treatment
(age;
sex; previous surgery: cholecystectomy, choledocotomy,
gastroduodenal surgery; severe acute pancreatitis;
cholangitis;
CBD stenosis, peri-ampullary diverticulum; CBD diameter)
have been studied in a binary logistic regression model. In
this
model, the CBD diameter was transformed into a qualitative
variable by dividing the population into two distinct
groups:
those with a CBD < 15 mm in diameter (normal caliber or
mild
to moderate dilatation) and those with dilated CBD exceeding
15 mm in diameter. A p value
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Table 3: Comparison of early complication in the two groups
Complications Group I Group II p
Papillary bleeding 3,8% 2,6%
Acute pancreatitis 1% 1,2%
Perforation 0% 0,5%
Cholangitis 1% 0,5%
Impacted Dormia basket 2% 0%
Total 7,8% 4,8% 0,37
Table 4: factors associated with overall success rate of
endoscopic treatment of multiple and/or large choledochal stones
in
univariate and multivariate analysis.
Independent variables Univariate analysis Multivariate
analysis
OR CI 95% p OR CI 95% p
Age 0,94 0,91-0,98 0,04 0,98 0,94-1,04 0,6
Sex 1,24 0,48-3,22 0,6
Past surgery 2,01 0,78-5,19 0,1
Severe acute pancreatitis 0,40 0,12-1,29 0,1
Cholangitis 0,16 0,06-0,43
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treatment failure were multiple choledochal stones and
surgical
choledocotomy. The early complication rate was also higher
in
patients with large stones (more than 2 cm). In our study,
the
presence of multiple and/or large stones did not
significantly
affect the rate of early complications. Several
studies11,12,26,27
have shown that the use of complementary techniques did not
significantly increase the morbidity of endoscopic
treatment.
CONCLUSION
Multiple and/or large choledochal stones are certainly a
difficulty in endoscopic management of CBD lithiasis, but
the
use of complementary maneuvers allowed us to carry up the
success rate from 64% to 89% with no significant increase in
early complications. The presence of cholangitis,
periampullary
diverticulum and /or CBD stenosis seem to be factors
associated
with a lower overall success rate of endoscopic treatment.
To
confirm these results, more prospective randomized studies
with
larger series are needed.
ACKNOWLEDGEMENTS
Authors do not want to configure any acknowledgments and
disclose no financial relationships relevant to this
publication.
Conflict of interests: none
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