From the Guidelines
The risk of recurrent choledocholithiasis after ERCP with stent and sphincterotomy is approximately 10% or less, considering the high success rate of stone removal during the procedure, as reported in recent studies 1. The mainstay of therapy for choledocholithiasis is endoscopic biliary sphincterotomy and stone extraction during ERCP, with a reported success rate of 90% 1. Some key points to consider in the management and follow-up of these patients include:
- The success rate of lithotripsy, which may be required for large stones, is around 79%, but multiple sessions may be needed to clear the stones completely 1.
- Placement of an internal plastic stent is standard in cases of incomplete stone extraction or severe acute cholangitis to ensure adequate biliary drainage 1.
- Risk factors that may increase the likelihood of recurrence include multiple stones at initial presentation, dilated bile ducts, periampullary diverticula, and certain medical conditions.
- Preventive measures for high-risk patients can include ursodeoxycholic acid, maintaining adequate hydration, and avoiding rapid weight loss.
- Follow-up imaging is not routinely recommended in asymptomatic patients but should be performed promptly if symptoms develop, such as right upper quadrant pain, jaundice, fever, or elevated liver enzymes, which may indicate stone recurrence.
From the Research
Risk Factors for Recurrent Choledocholithiasis
The risk of recurrent choledocholithiasis after Endoscopic Retrograde Cholangiopancreatography (ERCP) with stent and sphincterotomy is a significant concern. Several studies have identified various risk factors associated with the recurrence of choledocholithiasis after ERCP. These include:
- Age > 65 years 2
- Combined history of choledocholithotomy 2
- Endoscopic papillary balloon dilation 2
- Endoscopic sphincterotomy 2, 3, 4
- CBD stent implantation 2
- Multiple ERCP procedures (≥2) 2
- Stones in the intrahepatic bile duct 2
- Periampullary diverticula 2, 3, 4
- Choledocholithiasis diameter ≥ 10 mm 2
- Bile duct-duodenal fistula 2
- Combined biliary tract infections 2
- No preoperative antibiotic use 2
Long-term Outcomes and Complications
Long-term follow-up studies have shown that patients who undergo ERCP with stent and sphincterotomy are at risk of developing late complications, including stone recurrence, acute acalculous cholangitis, and acute cholecystitis 3, 4, 5. The risk of these complications can be mitigated with regular follow-up and prompt treatment of recurrent stones 5.
Management of Recurrent Choledocholithiasis
Repeat ERCP is a reasonable treatment option for recurrent choledocholithiasis after ERCP with stent and sphincterotomy 3, 4. However, careful follow-up is necessary to detect recurrent stones early and avoid complications of bile duct stones 5. Understanding the pathophysiology of stent clogging and recognizing the optimal interval for stent replacement may help reduce the risk of stent clogging and potentially fatal acute cholangitis 6.
Recurrence Rates
The recurrence rates of choledocholithiasis after ERCP with stent and sphincterotomy vary depending on the study. One study reported a first recurrence rate of 19.5% and a second or subsequent recurrence rate of 44.07% 2. Another study reported a recurrence rate of 11.9% over a median follow-up period of 14.5 years 4. Regular follow-up and prompt treatment of recurrent stones can help reduce the risk of complications and improve outcomes 5.