Retrospective Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2019; 25(4): 485-497
Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.485
Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones
Xiao-Dong Zhou, Qiao-Feng Chen, Yuan-Yuan Zhang, Ming-Ju Yu, Chang Zhong, Zhi-Jian Liu, Guo-Hua Li, Xiao-Jiang Zhou, Jun-Bo Hong, You-Xiang Chen
Xiao-Dong Zhou, Qiao-Feng Chen, Yuan-Yuan Zhang, Ming-Ju Yu, Chang Zhong, Zhi-Jian Liu, Guo-Hua Li, Xiao-Jiang Zhou, Jun-Bo Hong, You-Xiang Chen, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
Author contributions: Zhou XD and Chen QF contributed equally to this work; Chen QF and Zhang YY designed the study and drafted the manuscript; Yu MJ collected and analyzed the data; Zhong C collected the data; Liu ZJ, Li GH, Hong JB, and Zhou XJ revised the manuscript for important intellectual content; Zhou XD and Chen YX made substantial contributions to conception, design, and coordination of the study and gave final approval of the version to be published. All authors have read and approved the final manuscript.
Institutional review board statement: This study was approved by the institutional review board of The First Affiliated Hospital of Nanchang University.
Informed consent statement: All involved persons provided written or verbal informed consent prior to study inclusion.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: You-Xiang Chen, MD, PhD, Chief Doctor, Professor, Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang 330006, Jiangxi Province, China. chenyx102@126.com
Telephone: +86-13879169980 Fax: +86-791-88692505
Received: November 17, 2018
Peer-review started: November 19, 2018
First decision: November 29, 2018
Revised: December 13, 2018
Accepted: January 9, 2019
Article in press: January 10, 2019
Published online: January 28, 2019
Processing time: 71 Days and 3.3 Hours
Abstract
BACKGROUND

Endoscopic sphincterotomy (EST) for the management of common bile duct stones (CBDS) is used increasingly widely because it is a minimally invasive procedure. However, some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and accompanied by a higher recurrence of CBDS than open choledochotomy (OCT). Whether any differences in outcomes exist between these two approaches for treating CBDS has not been thoroughly elucidated to date.

AIM

To compare the outcomes of EST vs OCT for the management of CBDS and to clarify the risk factors associated with stone recurrence.

METHODS

Patients who underwent EST or OCT for CBDS between January 2010 and December 2012 were enrolled in this retrospective study. Follow-up data were obtained through telephone or by searching the medical records. Statistical analysis was carried out for 302 patients who had a follow-up period of at least 5 years or had a recurrence. Propensity score matching (1:1) was performed to adjust for clinical differences. A logistic regression model was used to identify potential risk factors for recurrence, and a receiver operating characteristic (ROC) curve was generated for qualifying independent risk factors.

RESULTS

In total, 302 patients undergoing successful EST (n = 168) or OCT (n = 134) were enrolled in the study and were followed for a median of 6.3 years. After propensity score matching, 176 patients remained, and all covariates were balanced. EST was associated with significantly shorter time to relieving biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT (P < 0.001). The number of complete stone clearance sessions increased significantly in the EST group (P = 0.009). The overall incidence of complications and mortality did not differ significantly between the two groups. Recurrent CBDS occurred in 18.8% (33/176) of the patients overall, but no difference was found between the EST (20.5%, 18/88) and OCT (17.0%, 15/88) groups. Factors associated with CBDS recurrence included common bile duct (CBD) diameter > 15 mm (OR = 2.72; 95%CI: 1.26-5.87; P = 0.011), multiple CBDS (OR = 5.09; 95%CI: 2.58-10.07; P < 0.001), and distal CBD angle ≤ 145° (OR = 2.92; 95%CI: 1.54-5.55; P = 0.001). The prediction model incorporating these factors demonstrated an area under the receiver operating characteristic curve of 0.81 (95%CI: 0.76-0.87).

CONCLUSION

EST is superior to OCT with regard to time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay and is not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS.

Keywords: Common bile duct stone; Choledochotomy; Endoscopic sphincterotomy; Outcome; Recurrence; Risk factor

Core tip: Therapeutic outcomes of endoscopic sphincterotomy (EST) and open choledochotomy (OCT) for the management of common bile duct stones (CBDS) have rarely been compared. The present study is the first to report on this issue and may represent the best evidence comparing these two interventions. The current results show that EST had more satisfactory short-term outcomes, including shorter time to biliary obstruction relief, anesthetic duration, procedure time, and hospital stay, than OCT. In addition, EST was not associated with a higher risk of subsequent recurrent CBDS or overall mortality.