Clearing common bile duct stones with Endoscopic Retrograde Cholangiopancreaticography (ERCP) requires multiple procedures to obtain clearance and is often accompanied by post-procedure complications, which seems to indicate limited efficacy, according to a study published in the Scandinavian Journal of Gastroenterology.
Although there is no consensus on treatment of common bile duct stones, the gold standard is the well-established 2-stage treatment with ERCP followed by laparoscopic cholecystectomy, depending on comorbidity, age and patient choice, despite the fact that it often requires multiple procedures before clearance is obtained. This single-center, prospective cohort study was designed to describe the clinical course from diagnosis of common bile duct stones to successful clearance with ERCP at a public university hospital. Participants (N=297) were adult patients with common bile duct stones undergoing ERCP for the first time between 2011 and 2014, and without previous cholecystectomy or ERCP, suspicion of bile leakage, or cancer. During and after the procedure, the endoscopist evaluated ERCP outcomes and then entered the data into the database. Three surgeons reviewed the electronic patient records to obtain follow-up data, which were reviewed by one surgeon to avoid misclassification.
Among the total 297 participants, 174 (59%) required >1 ERCP and of these, 123 (41%) required 2 ERCP procedures, 36 (12%) required 3, and 5% required >4 ERCPs to obtain stone clearance (12 needed 4 ERCPs, 2 needed 5 ERCPs, and 1 needed 6 ERCPs). Additionally, 269 (91%) participants were given sphincterotomies and 189 (64%) had stents inserted. Seventeen (6%) participants experienced bleeding that required injection treatment and 38 (13%) experienced complications post-procedure. In 180 (61%) participants, subsequent laparoscopic cholecystectomies were performed, for a mean 2.5 procedures were patient (SD=1.1). The overall length of hospitalization was 11 (SD=8.5) days, and length of clinical course from diagnosis to clearance was 49 (SD=84.5) days. Logistic regression analyses found an association between ERCP failure and asthma and inverse associations between ERCP failure and overweight, baseline pancreatitis, universal anesthesia, and expert endoscopist. A limitation of the study is that the reports were based on data from a single center.
Study investigators concluded that although the optimum treatment course for common bile duct stones has not yet been determined, “ERCP for CBD stone clearance involves multiple interventions, prolonged treatment, causes post procedure morbidity and high treatment costs. Newer studies have shown single stage procedures for stone removal in conjunction to laparoscopic cholecystectomy to be safe and shorten the treatment duration.”
Nielsen LBJ, Shabanzadeh DM, Aaresøn A, Sørensen LT. The clinical course of common bile duct stone clearance with endoscopic retrograde cholangio-pancreaticography [published online September 17, 2019]. Scand J Gastroenterol. doi: 10.1080/00365521.2019.1663259