endoscopic management of multiple and large choledochal...

Adioui et al. Int J Gastroenterol Hepatol Transpl Nutr 2017;2(i): 18-22 ISSN 2455–9393

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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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