Clinical Research Of Recurrence Of Common Bile Duct Stones After Endoscopic Sphincterotomy (EST)

Background:Cholelithiasis is a common disease in China. At present, with the improvement of people’s living standard, the incidence of gallstones with a rising trend year by year. According to the different parts of stones, cholelithiasis including intrahepatic bile duct stones, extrahepatic bile duct stones and gallbladder stones. The extrahepatic bile duct stones, which typical manifestations are abdominal pain, fever and jaundice, known as Charcot triad, has more clinical significance than other types of gallstones, because it can lead to complications of cholangitis, pancreatitis, biliary obstruction and other serious diseases. The long-term existence of bile duct stones, to the patient’s body and economy with a double whammy, seriously affecting the quality of life of patients, can lead to cirrhosis when combined with intrahepatic bile duct stones.So once the discovery of extrahepatic bile duct stones,the patients need operation treatment immedately to remove stones. The common bile duct stones can be treated by minimally invasive endoscopic stone extraction, common bile duct exploration and laparoscopic common bile duct exploration and other operation treatments. With endoscopic technology gradually mature, endoscopic retrograde cholangiopancreatography(ERCP) already became an important means of treatment from diagnosis technology. ERCP combined with endoscopic sphincterotomy(EST) which in treatment of papillary sphincter dysfunction and other operations in bile duct has also made considerable progress. With the advantage of short time, fewer complications, small traumat, EST has become the first choice of the treatment of bile duct stones. But minimally invasive operation is still unable to significantly reduce the recurrence rate of bile duct stones.There are a lot of literatures study on the factors influencing the recurrence of common bile duct stones, including doudenal diverticulum, stone size, bile duct dilatation and other factors, but the different degree of sphincterotomy effect on the recurrence of common bile duct stones is still controversial, laking of strong evidence based on this theory.Objective:Through the observation the stone recurrence rate of common bile duct calculi were treated by ERCP+EST, to explore the different degree of sphincterotomy effects on common bile duct stone recurrence.Subjects and Methods:1、All patients(289) who were treated for choledocholithiasis by means of endoscopic retrograde cholangiopancreatography(ERCP) with EST between January2009and December2012in Shangdong Province-owned Hospital. Their medical records were retrospectively reviewed. Among them, patients who met the following criteria were unselected:①Associated with malignant biliary obstruction;②With benign stricture of upper of common bile duct; or by EST or dilated balloon still exists common bile duct stenosis;③With cystic dilatation of common bile duct;④With intrahepatic bile duct stone and endoscopic cannot remove or failed to take the stones;⑤The patients with severe liver diseases, such as cirrhosis, liver failure;⑥The blood system diseases, with abnormal blood coagulation function;⑦The common bile duct stone recurrence after the treatment of EST or CBDE;⑧Ater the Billroth Ⅱ gastrectomy.Consequently, in total289patients were enrolled in the study.2、In order to avoid the influence of artificial factors, the operation of the selected cases were performed by the same surgeon. Consider the patients’duodenal papilla shape, stone size and open space and other factors, to the duodenal papilla in the intestinal lumen uplift incision marks, to determine the length of incision:①Large incision refers to the cut reach the export side of nipple bulge, only open twist head fold for the middle cut, not cut twist head fold for small incision.②When the nipple without obvious twist head fold, large incision since the papillae cut to the base of the nipple; middle incision since opening cut nipple4/5; small incision from the papillae cut nipple1/2to3/5.③When the nipple is narrow, breast dysplasia, nipple with a hole shape or fully in the diverticulum, no twist head fold or nipple bulge, incision length is less than8mm, such EST are called small incision.3、After EST, we performed a regular check-up on each patient at the outpatient department base, and considered absence of choledocholithiasis recurrence by using telephone interviews in patients who were missed. Compared the recurrence rate of choledocholithiasis in different level of papilla sphincter incision.Results:Records of318patients with telephone follow-up results and referral situation.11patients died, could not be contacted in18cases, finally get the exact follow-up results of289cases (166men,123women; age11-88years old, mean age58.55years old). Recurrence in patients with a total of48cases, the total recurrence rate was16.61%.The nipple of small incision85cases patients,20cases of postoperative recurrence (recurrence rate23.53%), milldle incision group had124cases,21cases of postoperative recurrence (recurrence rate16.94%),80cases of patients with lager papillary incision, postoperative recurrence in7cases(recurrence rate8.75%), chi square test:(1) The difference of groups of common bile duct stone recurrence rate was statistical significance (P=0.0385<0.05).(2) The lager nipple incision recurrence rate was significantly lower than that in small and milldle incision group, the difference was statistically significant (P<0.05).(3) The smal lnipple incision group of gallstone recurrence rate was significantly higher than that in large and middle incision group, the difference was statistically significant difference (P<0.05). Conclusion:Sphincterotomy with different degrees of common bile duct stone recurrence rate has a significant impact, papillary sphincterotomy to remove large pathologic nipple sphincter dysfunction, promote bile excretion smooth, is to reduce the recurrence of common bile duct stone;...