Published online Jan 28, 2019. doi: 10.3748/wjg.v25.i4.485
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
Endoscopic sphincterotomy (EST) and open choledochotomy (OCT) are two common therapeutic modalities for the management of common bile duct stones (CBDS). Over time, EST as a minimally invasive approach has become safe, efficient, and cost-effective. However, it remains unclear whether there are any differences in outcomes between these two approaches for the treatment of CBDS.
Some clinical practitioners argued that EST may be complicated by post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) and are associated with a higher recurrence of CBDS than OCT. Additionally, the risk factors associated with recurrence have not yet been established firmly. We wanted to investigate these issues to help guide clinicians in efforts to manage CBDS better.
The retrospective study aimed to compare the clinical outcomes of EST vs OCT for the management of CBDS and to identify the risk factors associated with stone recurrence.
This study included 302 patients with CBDS who met the criteria. The short- and long-term clinical outcomes were compared between the EST and OCT groups. Propensity score matching was performed to adjust for the effects of confounding factors. Recurrence of CBDS was calculated by the Kaplan-Meier method with the use of the log-rank test. Risk factors for recurrence were identified using a logistic regression model.
EST was associated with shorter time to relieving the biliary obstruction, anesthetic duration, procedure time, and hospital stay than OCT. The overall incidence of complications and mortality did not differ significantly between the two groups. There was no significant difference in recurrence rate between the EST (18/88, 20.5%) and OCT (15/88, 17.0%) groups. The area under the receiver operating characteristic (ROC) curve for the logistic regression model incorporating CBD diameter ≥ 15 mm, multiple CBDS, and distal CBD angle ≤ 145° was 0.81 (95%CI: 0.76-0.87).
EST shows better results in short-term outcomes, including shorter time to relief of biliary obstruction, anesthetic duration, procedure time, and hospital stay, and was not associated with an increased recurrence rate or mortality compared with OCT in the management of CBDS. CBD dilatation, multiple CBDS, and distal CBD angle ≤ 145° are independent risk factors for CBDS recurrence, and these factors may help screen out high-risk patients who require follow-up more frequently.
EST can be performed safely without posing a higher risk of subsequent recurrent CBDS or overall mortality than OCT. Additional randomized controlled trials are needed to further validate these findings.