Prospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2021; 27(4): 358-370
Published online Jan 28, 2021. doi: 10.3748/wjg.v27.i4.358
Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study
Yan-Yan Lin, Yu-Dong Wang, Ping Yue, Xian-Zhuo Zhang, Joseph W Leung, Pan-Pan Jiao, Man Yang, Hai-Ping Wang, Bing Bai, Ying Liu, Jin-Duo Zhang, Hong-Bo Chen, Wen-Bo Meng, Xun Li
Yan-Yan Lin, Ping Yue, Xian-Zhuo Zhang, Bing Bai, Jin-Duo Zhang, Wen-Bo Meng, Xun Li, Department of General Surgery, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
Yan-Yan Lin, Ping Yue, Hai-Ping Wang, Bing Bai, Jin-Duo Zhang, Wen-Bo Meng, Xun Li, Clinical Medical College Cancer Center of Lanzhou University, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
Yan-Yan Lin, Ping Yue, Hai-Ping Wang, Bing Bai, Jin-Duo Zhang, Wen-Bo Meng, Xun Li, Key Laboratory of Biological Therapy and Regenerative Medicine Transformation of Gansu Province, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
Yu-Dong Wang, Department of General Surgery, The First Affiliated Hospital of Henan Polytechnic University, Jiaozuo 454001, Henan Province, China
Xian-Zhuo Zhang, Pan-Pan Jiao, The First School of Clinical Medicine, Lanzhou University, Lanzhou 730000, Gansu Province, China
Joseph W Leung, Department of Gastroenterology, Sacramento VA Medical Center, Mather, CA 95655-4200, United States
Joseph W Leung, Department of Gastroenterology and Hepatology, UC Davis Medical Center, Sacramento, CA 95817, United States
Man Yang, Department of Gastroenterology, Songgang People’s Hospital, Shenzhen 518105, Guangdong Province, China
Ying Liu, School of Foreign Languages and Literatures, Lanzhou University, Lanzhou 730000, Gansu Province, China
Hong-Bo Chen, School of Pharmaceutical Sciences, Sun Yat-sen University, Shenzhen 518105, Guangdong Province, China
Author contributions: Lin YY, Wang YD, Yue P, and Zhang XZ contributed equally to this work; Lin YY, Wang YD, Yue P, Leung JW, and Meng WB contributed to study conception and design; Chen HB, Meng WB ,and Li X contributed to administrative support; Lin YY, Wang YD, Yue P, Zhang XZ, Jiao PP, Yang M, Bai B, Liu Y, and Zhang JD contributed to provision of study materials or patients; Lin YY, Wang YD, Yue P, Zhang XZ, Jiao PP, Yang M, Bai B, Liu Y, and Zhang JD contributed collection and assembly of the data; Lin YY, Wang YD, Yue P, Zhang XZ, Jiao PP, Leung JW, Wang HP, Chen HB, Meng WB, and Li X contributed to data analysis and interpretation; all authors wrote the manuscript, and have read and approved the final manuscript.
Supported by National Natural Science Foundation of China, No. 81872036 and No. 82060551.
Institutional review board statement: The study was approved by the ethics committee of The First Hospital of Lanzhou University (No. LDYYMENG2018-1028) and conducted in accordance with the ethical principles of the Declaration of Helsinki.
Clinical trial registration statement: This study is registered at ClinicalTrials.gov. The registration identification number is NCT03701009.
Informed consent statement: The patients were not required to give informed consent to the study because written informed consents were obtained from the patients for using their data anonymously in scientific studies while protecting their anonymity before the procedure.
Conflict-of-interest statement: All authors have no conflicts of interest to declare.
Data sharing statement: No additional data are available.
CONSORT 2010 statement: The authors have read the CONSORT 2010 statement, and the manuscript was prepared and revised according to the CONSORT 2010 statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: Wen-Bo Meng, MD, PhD, Professor, Department of General Surgery, The First Hospital of Lanzhou University, No. 1 Donggang West Road, Lanzhou 730000, Gansu Province, China. mengwb@lzu.edu.cn
Received: November 22, 2020
Peer-review started: November 22, 2020
First decision: November 30, 2020
Revised: December 11, 2020
Accepted: December 28, 2020
Article in press: December 28, 2020
Published online: January 28, 2021
Processing time: 64 Days and 1.6 Hours
Abstract
BACKGROUND

A previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.

AIM

To determine whether saline irrigation can improve CBD clearance after lithotripsy.

METHODS

This prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.

RESULTS

Between October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).

CONCLUSION

Irrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Keywords: Endoscopic retrograde cholangiopancreatography; Common bile duct gall stones; Peroral cholangioscopy; Saline irrigation; Periampullary diverticula; Prospective cohort study

Core Tip: This is a prospective self-controlled study with 47 patients seeking to determine whether saline irrigation can also improve common bile duct (CBD) clearance after mechanical lithotripsy. Irrigation with 100 mL of saline may not clear all residual CBD stones after mechanical lithotripsy, especially in patients with periampullary diverticula (PAD) and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove the retained stones.