Is Endoscopic Retrograde Cholangiopancreatography with Balloon Sweeps a Must in Postcholecystectomy Stent Removal for Choledocholithiasis?

Abstract

Objectives This study aims to evaluate whether stent removal through endoscopic retrograde cholangiopancreatography (ERCP) with balloon sweeps is necessary or whether stent removal by forward-viewing gastroscope without cholangiogram is sufficient.

Materials and Methods A prospective, single-center study was conducted from April 2022 to March 2023 for 1 year. Adult patients with choledocholithiasis who underwent common bile duct (CBD) clearance and CBD stenting followed by cholecystectomy were included. Then, they underwent CBD stent removal either by gastroscope directly or by side-viewing endoscopy with balloon sweeps and occlusion cholangiogram. Recurrence of stones and complications after stent removal were studied in both groups.

Results Forty-seven patients were enrolled in the final study. A total of 64% of patients (n = 30) underwent CBD stent removal followed by balloon sweeps and cholangiogram, and the remaining 34% (n = 17) patients underwent direct stent removal. Time taken for the procedure was more in the balloon sweeps group compared with the direct stent removal group and was statistically significant. No statistically significant adverse events were seen in both groups.

Conclusion Patients who underwent CBD stenting for choledocholithiasis after cholecystectomy can safely undergo stent removal using a gastroscope rather than be subjected again to ERCP. This will significantly reduce the duration, unplanned adverse events, and cost of ERCP.

Keywords

Choledocholiathiasis - Cholecystectomy - Endoscopic retrograde cholangiopancreaticography - Gastroscope

Author Contributions

Conceptualization: D.S., M.I., S.L.; formal analysis: D.S., S.L., C.T., V.R., M.S.; project administration: D.S.; writing—original draft: D.S., S.L., C.T., V.B.; writing—review and editing: D.S., K.B., M.S., S.C., Y.L.

Ethics Committee Approval

The study was approved by the Institutional Ethics Committee Board at Lokmanya Tilak Municipal Medical College, Sion Hospital, Mumbai, India.

Publication History

Article published online:
02 September 2024

• References

• 1 De Silva WSL, Pathirana AA, Wijerathne TK, Gamage BD, Dassanayake BK, De Silva MM. Epidemiology and disease characteristics of symptomatic choledocholithiasis in Sri Lanka. Ann Hepatobiliary Pancreat Surg 2019; 23 (01) 41-45
• 2 Alponat A, Kum CK, Rajnakova A, Koh BC, Goh PM. Predictive factors for synchronous common bile duct stones in patients with cholelithiasis. Surg Endosc 1997; 11 (09) 928-932
• 3 Deng F, Zhou M, Liu PP. et al. Causes associated with recurrent choledocholithiasis following therapeutic endoscopic retrograde cholangiopancreatography: a large sample sized retrospective study. World J Clin Cases 2019; 7 (09) 1028-1037
• 4 Horiuchi A, Nakayama Y, Kajiyama M. et al. Biliary stenting in the management of large or multiple common bile duct stones. Gastrointest Endosc 2010; 71 (07) 1200-1203.e2
• 5 SPSS Inc. IBM SPSS Statistics Version 22 Statistical Software: Core System Users' Guide. SPSS Inc. 2014.
• 6 Sarli L, Pietra N, Franzé A. et al. Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy. Gastrointest Endosc 1999; 50 (02) 200-208
• 7 Shah KN, Clary BM. Chapter 36A - Stones in the bile duct: clinical features and open surgical approaches and techniques. In: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6^th ed, Vol. 1–2;2017.
• 8 Gupta AM, Ramteke S, Kanwar KS. et al. Study of morphological spectrum of gallstone and bacteriology of bile in cholelithiasis. Int Surg J 2017; 4: 177-180
• 9 Selvi TR, Sinha P, Subramaniam PM. et al. A clinicopathological study of cholecystitis with special reference to analysis of cholelithiasis. Iran J Basic Med Sci 2011; 2: 68-72
• 10 Ponugoti S, Juluri R, Sundaram U. Is a follow-up endoscopic retrograde cholangiopancreatography procedure necessary for removal of biliary stents?: 1920. Am J Gastroenterol 2013; 108: S582
• 11 Andriulli A, Loperfido S, Napolitano G. et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol 2007; 102 (08) 1781-1788
• 12 Nair MS, Uzzaman MM, Fafemi O, Athow A. Elective laparoscopic cholecystectomy in the presence of common bile duct stent. Surg Endosc 2011; 25 (02) 429-436
• 13 Freeman ML, Nelson DB, Sherman S. et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996; 335 (13) 909-918
• 14 Tsujino T, Isayama H, Komatsu Y. et al. Risk factors for pancreatitis in patients with common bile duct stones managed by endoscopic papillary balloon dilation. Am J Gastroenterol 2005; 100 (01) 38-42
• 15 Ando T, Tsuyuguchi T, Okugawa T. et al. Risk factors for recurrent bile duct stones after endoscopic papillotomy. Gut 2003; 52 (01) 116-121
• 16 Kim DI, Kim MH, Lee SK. et al. Risk factors for recurrence of primary bile duct stones after endoscopic biliary sphincterotomy. Gastrointest Endosc 2001; 54 (01) 42-48
• 17 Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction. Surg Endosc 2006; 20 (10) 1594-1599
• 18 Cheon YK, Lehman GA. Identification of risk factors for stone recurrence after endoscopic treatment of bile duct stones. Eur J Gastroenterol Hepatol 2006; 18 (05) 461-464
• 19 Keizman D, Ish Shalom M, Konikoff FM. Recurrent symptomatic common bile duct stones after endoscopic stone extraction in elderly patients. Gastrointest Endosc 2006; 64 (01) 60-65
• 20 Hawes RH, Cotton PB, Vallon AG. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy. Gastroenterology 1990; 98 (04) 1008-1012
• 21 Coelho-Prabhu N. et al. Is repeat ERCP required at the time of biliary stent removal after clinical resolution of an endoscopically managed post- cholecystectomy bile leak?. Gastrointest Endosc 2009; 69 (05) AB151