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