Chul Woong Kim Ju Ik Moon In Seok Choi Department of Surgery Konyang University Hospital Daejeon Korea Introduction Management of CBD stone ERCP with EST and stone extraction First line management ID: 1044442
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1. Risk factors for stone recurrence after laparoscopic common bile duct exploration of CBD stonesChul Woong Kim, Ju Ik Moon, In Seok ChoiDepartment of Surgery, Konyang University Hospital, Daejeon, Korea
2. IntroductionManagement of CBD stone ERCP with EST and stone extraction (First line management)Laparoscopic CBD exploration with stone extraction (Alternative therapeutic approach ) Gastrointestinal Endoscopy, Volume 74, No. 4 : 2011 The American Journal of Surgery, Vol 206, No 4, October 2013Recurrent rate of endoscopic treatment : 5 – 30 % Korean J Gastroenterol 2015;66:251-254
3. IntroductionRisk factor of recurrence CBD stone after ERCPPrevious cholecystectomyMechanical lithotripsy CBD duct dilatation & Stricture of CBDExisted of diverticulum around ampulla of vaterCBD angle : under 145˚ Gastrointestinal Endoscopy 2004 ; Volume 59 : AB197 Gastroenterology. 1990 Apr ; 98(4) : 1008-12 Gastrointest Endoscopy 1998 Nov; Volume 48 : 457-64 Gastrointest Endoscopy 2001 ; Volume 54 : 42-48 Gastroenterol Hepatology 2006 May;18(5):461-4
4. PurposeHowever, risk factors of stone recurrence after laparoscopic CBD exploration are still not established.To identify risk factors for stone recurrence after laparoscopic CBD exploration
5. Materials and methodsPatientsMarch 2001 ~ December 2015, Retrospective reviewKonyang University Hospital, Daejeon, KoreaTotal 279 patients treated with laparoscopic CBD explorationExclusionTotal 24 patientsIntrahepatic duct (IHD) stones : 19 patientsCombine operation : 3 patientsCBD exploration undergone in other hospitals : 2 patients
6. Materials and methods9.4 %
7. MethodsCompared with recurrent 24 patients and no recurrent 231 patients Recurrence of stones : 12 months after opMean of recurrent months : 43.7 monthsFollow up : 1 month after op Lab data - LFT, Ultrasonography 12 month after op – CT scan or MRCP Analyzed factorsAge, Sex, BMIOperative factors : operation time, blood loss Duration of admission periodStone size , multiple or single stone , duct dilatationPrevious endoscopic sphincterotomy (EST)Materials and methods
8. ResultsVariablesAll patients (n=255)Age (years)70.9 ± 13.6SexMale119 (46.7%)Female136 (53.3%)BMI (Kg/m²)22.6 ± 3.9< 25 Kg/m²196 (76.9%)≥ 25 Kg/m²59 (23.1%)Previous surgery Hx.Upper47 (18.4%)Lower20 (7.8%)ASA score< 3170 (66.7%)≥ 385 (33.3%)Operation time (min)116.4 ± 57.4Blood loss (ml)55.4 ± 104.2T-tube insertion22 (8.6%)Table 1. Patient characteristic : diagnosed CBD stoneVariablesAll patients (n=255)Hospital stay (days)6.6 ± 3.6Complication 13 (5.1 %)Stone size (mm) 13.1 ± 7.9 < 13 mm121 (47.5%)≥ 13 mm134 (52.5%)Previous CBD stone historyyes16 (6.3%)Previous cholecystectomyyes20 (7.8%)Previous ESTyes55 (21.6%)Duct dilatationyes193 (75.7%)Multiple stone yes165 (64.7%)Follow up (months)56.7 ± 44.9
9. ResultsVariables No recurrence (n=231)Recurrence (n=24)P valueAge (yrs)70.9 ± 13.970.9 ± 10.10.994< 80163 (70.6%)19 (79.2%)0.480≥ 8068 (29.4%)5 (20.8%)SexMale124 (53.7%)12 (50.0%)0.831Female107 (46.3%)12 (50.0%)BMI (kg/m2)22.6 ± 4.022.4 ± 2.80.699< 25 Kg/m²176 (76.2%)20 (83.3%)0.612≥ 25 Kg/m²55 (23.8%)4 (16.7%)Previous surgery Hx.Upper42 (18.2%)5 (20.8%)0.941Lower18 (7.8%)2 (8.3%)ASA score< 3151 (65.4%)19 (79.2%)0.255≥ 380 (34.6%)5 (20.8%)Table 2. Univariate analysis for risk factors in recurrent CBD stone
10. ResultsVariables No recurrence (n=231)Recurrence (n=24)P valueOperation time (min)116.3 ± 57.7117.6 ± 55.90.914Blood loss (ml)55.6 ± 105..052.9 ± 98.80.900Hospital stay (days) 6.4 ± 3.4 8.3 ± 5.00.015Stone size (mm)13.1 ± 8.112.9 ± 5.40.896< 13 mm107 (46.3%)14 (58.3%)0.289≥ 13 mm124 (53.7%)10 (41.7%) Previous CBD stone Hx.yes14 (6.1%)2 (8.3%)0.653Previous cholecystectomyyes16 (6.9%)4 (16.7%)0.104Previous ESTyes45 (19.5%)10 (41.7%)0.018Duct dilatationyes172 (74.5%)21 (87.5%)0.213Multiple stoneyes144 (62.3%)21 (87.5%)0.013Follow up (months)51.5 ± 41.9106.1 ± 42.9< 0.001Table 2. Univariate analysis for risk factors in recurrent CBD stone
11. ResultsVariables Hazard ratio95% CIP valueMultiple stone3.8221.088 – 13.4320.037Previous EST2.7131.013 – 7.2650.047Table 3. Multivariate analysis for risk factors in recurrent CBD stone
12. ConclusionAccording to our results, patients who have multiple stones and previous EST were statistically significant higher recurrent rates after laparoscopic CBD exploration of CBD stonesSo, these patients should be considered careful observation and necessary long term follow up