|Year : 2019 | Volume
| Issue : 4 | Page : 1229-1233
Necessity of stent placement after successful common bile duct stone clearance by endoscopic retrograde cholangiopancreatography
Hatem M Sultan1, Tarek M Rageh1, Ashraf MA Alsoaood2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Damanhour Medical National Institute, Damanhour, Egypt
|Date of Submission||10-Jul-2018|
|Date of Decision||23-Aug-2018|
|Date of Acceptance||26-Aug-2018|
|Date of Web Publication||31-Dec-2019|
Ashraf MA Alsoaood
Source of Support: None, Conflict of Interest: None
The aim was to evaluate the role of stent insertion in the common bile duct after complete stone clearance by endoscopic retrograde cholangiopancreatography (ERCP).
Biliary stents are usually inserted when complete stone clearance cannot be achieved. However, stent insertion after clearance may lower the pressure in the bile ducts and provide better bile drainage, thus preventing recurrent biliary events.
Patients and methods
This is a prospective study that was done on a consecutive sample of 40 patients who were admitted to Menoufia University Hospital during the period between May 2016 and May 2018 with choledochocystolithiasis, who underwent complete stone clearance by ERCP. The patients were divided into two groups: group I with bile duct stent insertion and group II without bile duct stent insertion. The patients were followed up for 1 month. The complications and the outcome of the operation were recorded.
Three cases were omitted due to failed ERCP: 10.5% of group II developed recurrent obstructive jaundice, 5.3% needed repeat emergency ERCP compared with 5.6 who developed obstructive jaundice and needed emergency ERCP in group II and 5.6% of group I developed pancreatitis. Conversion to open cholecystectomy was done only in 5.6% of group I; 11.1% of group I had downward stent migration; 5.6% had upward migration; and 5.6% had their stent occluded.
Biliary stent insertion after choledocholithiasis clearance has the disadvantage of prolonging ERCP time, increasing its cost and the stent-related complications with no advantage for this group over the group without stent insertion.
Keywords: choledocholithiasis, common bile duct, endoscopic retrograde cholangiopancreatography, obstructive jaundice, stent
|How to cite this article:|
Sultan HM, Rageh TM, Alsoaood AM. Necessity of stent placement after successful common bile duct stone clearance by endoscopic retrograde cholangiopancreatography. Menoufia Med J 2019;32:1229-33
|How to cite this URL:|
Sultan HM, Rageh TM, Alsoaood AM. Necessity of stent placement after successful common bile duct stone clearance by endoscopic retrograde cholangiopancreatography. Menoufia Med J [serial online] 2019 [cited 2020 Jun 6];32:1229-33. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1229/274240
| Introduction|| |
Gallstone disease is a leading cause for hospital admissions related to gastrointestinal problems .
The incidence is four times higher in women than in men with high prevalence among the younger age group (20–30 years) .
The incidence of common bile duct stones (CBDS) has been reported as ranging between 5% and 18% of patients undergoing cholecystectomy for gallstones, and patients with symptoms suggestive of choledocholithiasis have an even higher incidence, which also increases with age .
The vast majority of CBDS forms within the gallbladder and then migrates into the common bile duct (CBD), following gallbladder contractions. Once in the CBD, stones may reach the duodenum following the bile flow; otherwise, also owing to the smaller diameter of the distal CBD at the Vater papilla, they may remain in the choledochus. In this latter case, gallstones may be fluctuant, thus remaining mostly asymptomatic, or cause a variety of bile flow problems, including complete obstruction and jaundice .
Obstructive jaundice is among the most challenging conditions managed by general surgeons and contributes significantly to high morbidity and mortality .
Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy is accepted as the therapy of choice for patients with stones in the bile duct. Endoscopic stone extraction is successful in more than 96% of patients .
Biliary endoprosthesis was first introduced to achieve biliary drainage in patients with irretrievable CBDS in the elderly population. In acute situations, biliary endoprostheses play an important role in achieving biliary drainage of the contaminated bile, thus, preventing complications from cholangitis, particularly after failed duct clearance . However, some endoscopists insert a prophylactic CBD stent at the time of ERCP to eliminate movement of the stones from the gallbladder to the CBD and the associated biliary complications .
The aim of this study was to assess the role of biliary stent insertion after complete choledocholithiasis clearance by ERCP.
| Patients and Methods|| |
This prospective study was done on a consecutive simple random sample of 40 patients who were admitted to the Menoufia University Hospital and satisfied the inclusion and exclusion criteria to be enrolled in the study during the period between May 2016 and May 2018. The study was completed in June 2017.
The procedure followed in the study is in accordance with the ethics committee of Menoufia Faculty of Medicine and written consents were taken from the patients or their guardians.
Inclusion criterion was patients presented by calcular obstructive jaundice with concomitant gallbladder stones.
Exclusion criterion was patients with CBDS that required mechanical lithotripsy for removal.
All patients were subjected preoperatively to detailed history taking and clinical examination. Their last investigations were revised from their files in the records.
ERCP was done with the patient in the prone position under general anesthesia on a radiographic table. Endoscope is introduced through the esophagus, stomach, and the duodenum, where identification of the major and minor duodenal papilla was done followed by cannulation of the major papilla and injection of radio contrast into the bile ducts.
Thorough fluoroscopy inspection of the CBD was performed with viewing any filling defects caused by CBDS, which were removed by a wired basket or balloon after performing sphincterotomy.
After complete CBDS clearance, the patients were divided into two groups according to whether or not to insert a biliary stent and the choice whether to insert a stent or not was done alternately between patients.
Subsequent to this withdrawal of the endoscope was done, followed by either same session laparoscopic cholecystectomy (LC) or delayed LC.
Postoperatively the patients were followed up for development of biliary complications such as pancreatitis, recurrent obstructive jaundice with subsequent need for emergency ERCP and stent-related complications such as stent occlusion, migration, and intestinal perforation. Also the rate of conversion of LC to open cholecystectomy (OC) and postoperative hospital stay were recoded.
Biliary stents were then removed 4 weeks after ERCP.
The collected data were organized, tabulated, and statistically analyzed using SPSS software (statistical package for the social sciences, version 19; SPSS Inc., Chicago, Illinois, USA). For quantitative data, the range, mean, and SD were calculated. For qualitative data, which describe a categorical set of data by frequency, percentage, or proportion of each category, comparison between two groups and more was done using the χ2-test. For comparison between means of two groups of parametric data of independent samples, Student t-test was used. For comparison between means of two groups of nonparametric data of independent samples, Z value of Mann–Whitney test was used. Significance was adopted at P less than 0.05 for the interpretation of results of tests of significance.
| Results|| |
The study was performed on 40 participants who were divided into two groups according to CBD stent insertion: group I included 20 patients who were planned to undergo stent insertion and group II included 20 patients who were not planned to be subjected to stent insertion.
Three cases were omitted from the study due to failed ERCP, so the study was completed on 18 patients of group I and 19 patients of group II.
The mean age of patients in group I was 47.00 ± 10.40 years, while the mean age for group II was 50.05 ± 10.14 years.
Female patients represented 72.2% in group I, while 84.2% of group II were women.
The mean CBD diameter which was assessed for all cases by ultrasonography prior to ERCP was 10.50 ± 1.54 for group I and 9.53 ± 1.92 for group II [Table 1].
|Table 1: Common bile duct diameter among the studied patients (with and without biliary stent placement) following successful stones clearance by endoscopic retrograde cholangiopancreatography (n=37)|
Click here to view
Two (10.5%) cases of group II developed obstructive jaundice after ERCP while only one (5.6%) case of group I developed obstructive jaundice [Figure 1].
|Figure 1: Postendoscopic retrograde cholangiopancreatography events among the studied patients.|
Click here to view
The need for repeated emergency ERCP was also assessed and it was almost equal for both groups: 5.6% for group I and 5.3% for group II [Figure 1].
The duration between ERCP and elective cholecystectomy was also recorded and analyzed and they were done in the same session in 22.2% of patients in group I and 31.6% of patients in group II.
Elective cholecystectomy was delayed after ERCP for 2–3 days in 33.3% of patients in group I and in 15.8% in group II, it was delayed for 4:5 days in 33.3% of patients in group I and 26.3% in group II and was delayed for 6–9 days in 11.1% of patients in group I and 26.3% in group II [Figure 1].
The rate of conversion from LC to OC was also recorded and we had to convert to open procedure in only one (5.6%) case of group I, while LC was completed successfully in all cases of group II [Figure 1].
Only one (5.6%) patient of group I developed pancreatitis after ERCP, while no patients in group II did [Figure 1].
During the follow-up period, stent-related complications in group I were also recorded and analyzed. Stent occlusion occurred in 5.6% of patients, downward migration of stent occurred in 11.1%, and upward migration occurred in 5.6%, while no stent-related perforation occurred [Figure 2].
|Figure 2: Biliary stent-related complications among the studied patients.|
Click here to view
The need for balloon trawl at stent removal was recorded in 11.1% of group I.
The mean postoperative hospital stay was 4.55 ± 3.09 days for group I, while it was 4.42 ± 2.32 days for group II [Table 2].
|Table 2: Postoperative hospital stay among the studied patients (with and without biliary stent placement) following successful stones clearance by endoscopic retrograde cholangiopancreatography (n=37)|
Click here to view
| Discussion|| |
The ERCP procedure originally involved endoscopic sphincterotomy and stone extraction, and some clinicians later added the insertion of a CBD stent at the time of ERCP before the cholecystectomy to prevent recurrent biliary complications, reduces operative morbidity, and shortens the hospital stay .
The placement of a stent in the CBD after ERCP before performance of a cholecystectomy is based on lowering the pressure in the bile ducts and providing better bile drainage in addition to preventing stone migration from the gallbladder to the CBD .
In a single center study of 603 cases of precholecystectomy CBD stones to assess the necessity of stent placement after ERCP, they concluded that 15.5% patients had repeat stones at the time of stent removal which is significant. Thus, it is logical and imperative to place a stent to prevent postoperative complications of leaks and cholangitis with jaundice .
The findings of a study by Huibregtse et al.  showed that although the initial placement of a stent in the CBD after ERCP clearance does result in lower pressure in the bile ducts and better bile drainage for a certain period, the stent itself may induce obstruction and predispose to infection later. In addition, long-term stents may increase the intraductal pressure within the biliary tree, thereby promoting inflammatory and fibrotic changes within the CBD wall.
In our study, the mean age of patients in group I was 47.00 ± 10.40 years with female patients representing 72.2% and the mean age for group II was 50.05 ± 10.14 years with female patients representing 84.2%, while in a study by Singh et al.  the mean age of the group of patients with CBD stent insertion was 61.4 ± 17.7 years with female patients representing 46.3% and the mean age for the group of patients without CBD stent insertion was 58.3 ± 19.4 years with female patients representing 66.7%.
Regarding the mean CBD diameter prior to ERCP, our study showed that it was 10.50 ± 1.54 for group I and 9.53 ± 1.92 for group II, while in the study by Verzhbitsky et al.  the mean CBD diameter of the group of patients with CBD stent insertion was 8.6 ± 2.9 mm and the mean diameter for the group of patients without CBD stent insertion was 8.2 ± 2.9 mm.
In our study, repeat emergency ERCP was done in 5.6% for group I and 5.3% for group II. The same percentage was found in the study by Verzhbitsky et al.  for the group of patients with CBD stent insertion, while it was 2% for the group of patients without CBD stent insertion.
ERCP and elective cholecystectomy were performed in the same session in 22.2% of patients in group I and 31.6% of patients in group II, while elective cholecystectomy was delayed after ERCP for 2:9 days in the rest of patients of both groups. The duration was longer in a study by Nair et al.  where it was 8–400 days in the group of patients with CBD stent insertion and 23–467 days in the group of patients without stent insertion.
The duration was shorter than that in the study by Verzhbitsky et al. , where it was 53.5 ± 68.8 days in the group of patients with CBD stent insertion and 41.0 ± 95.0 days in the group of patients without stent insertion.
Although conversion from LC to OC should never be considered a complication, it does lead to more postoperative infections, a longer hospital stay, and a longer convalescence .
In our study, LC was converted to OC in only one (5.6%) case of group I while LC was completed successfully in all cases of group II, which is quite different from the study by Nair et al.  where LC was converted to OC in 51.4% of patients with CBD stent and in 3.2% of patients without CBD stent insertion.
The rate of conversion is also different in the study by Verzhbitsky et al.  where LC was converted to OC in 8.2% of patients with CBD stent and in 5.8% of patients without CBD stent insertion.
In our study, only one (5.6%) patient of group I developed pancreatitis after ERCP, while no patients in group II did, while in a study by Wilcox et al.  0.82% of patients who underwent biliary sphincterotomy followed by biliary stenting, developed pancreatitis.
In our study, downward migration of stent occurred in 11.1% and upward migration occurred in 5.6%, which are smaller percentages compared with a study by Katsinelos et al. , where 41.2% of patients had stents that migrated proximally and 58.8% had distally migrated stents.
In our study, stent occlusion occurred in 5.6% of patients while in a study by Groen et al.  occlusion occurred in 20–30% after 3 months.
In our study the mean postoperative hospital stay was 4.55 ± 3.09 days for group I, while it was 4.42 ± 2.32 days for group II, whereas in the study by Nair et al.  the mean postoperative hospital stay was 11.67 ± 12.36 days for the group of patients with biliary stents while it was 1.65 ± 1.11 for the group of patients without biliary stent placement.
| Conclusion|| |
The results of our study did not show significant differences of statistical importance between the group who underwent biliary stent insertion and the group who did not. So we concluded that there is no advantage of inserting a biliary stent after complete CBD stone clearance as this will prolong the time and increase the cost of the procedure. Also biliary stent insertion exposes patients to stent-related complications and the need for another ERCP session for stent removal. Further studies over a larger group of patients and for a longer period is needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT, et al
. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006; 101
Shrestha HG, Bajracharya M. Incidence of cholelithiasis and its correlation with cancer of gallbladder at TU Teaching Hospital. JNMA 1991; 29
Martin DJ, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006; 2013
Costi R, Gnocchi A, di Mario F, Sarli L. Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy. World J Gastroenterol 2014; 20
Ahmad I, Jan AU, Ahmad R. Obstructive jaundice. J Postgrad Med Inst 2001; 15
Siddiqui A, Mitroo P, Loren D, Kowalski T. Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high risk surgical patients: a decision analysis. Gastrointest Endosc 2005; 61
Mohammed N, Pinder M, Harris K, Everett SM. Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management – tertiary-centre experience and systematic review. Frontline Gastroenterol 2016; 7
Verzhbitsky V, Zeina AR, Depsames R, Ovadia B, Atia O, Fireman Z. Does prophylactic stent insertion to the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy have any impact on the rate of biliary complications? Surg Endosc 2013; 27
Singh AN, Kilambi R. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones: systematic review and meta-analysis of randomized trials with trial sequential analysis. Surg Endosc 2018; 32
Donelli G, Guaglianone E, di Rosa R, Fiocca F, Basoli A. Plastic biliary stent occlusion: factors involved and possible preventive approaches. Clin Med Res 2007; 5
Desai PN, Kabrawala MV. Su1633 a single centre study of 603 cases of pre cholecystectomy CBD stones-to assess the necessity of stent placement after ERCP. Gastrointest Endosc 2014; 79
Huibregtse K, Tytgat GN. Palliative treatment of obstructive jaundice by transpapillary introduction of large bore bile duct endoprosthesis. Gut 1982; 23
Nair MS, Uzzaman MM, Fafemi O, Athow A. Elective laparoscopic cholecystectomy in the presence of common bile duct stent. Surg Endosc 2011; 25
Hendolin HI, Pääkkönen ME, Alhava EM, Tarvainen R, Kemppinen T, Lahtinen P. Laparoscopic or open cholecystectomy: a prospective randomised trial to compare postoperative pain, pulmonary function, and stress response. Eur J Surg 2000; 166
Wilcox CM, Phadnis M, Varadarajulu S. Biliary stent placement is associated with post-ERCP pancreatitis. Gastrointest Endosc 2010; 72
Katsinelos P, Kountouras J, Paroutoglou G, Chatzimavroudis G, Paikos D, Zavos C, et al
., Migration of plastic biliary stents and endoscopic retrieval: an experience of three referral centers. Surg Laparosc Endosc Percutan Tech 2009; 19
Groen AK, Out T, Huibregtse K, Delzenne B, Hoek FJ, Tytgat GN. Characterization of the content of occluded biliary endoprostheses. Endoscopy 1987; 19
[Figure 1], [Figure 2]
[Table 1], [Table 2]