Risk Factors And Score Of Recurrent Choledocholithiasis After ERCP In Patients With Cholecystectomy

Objectives:To investigate the related risk factors and recurrence rate of recurrent choledocholithiasis after retrograde endoscopic cholangiopancreatography in patients with cholecystectomy.At the same time,establish risk score mode,the recurrence of patients can be divided into low and high risk population,which can guide clinical diagnosis and treatment work,help clinicians to identify the people at high risk of recurrence.Corresponding measures preoperation,intraoperation and postoperation should be taken to prevent recurrence in high-risk groups,and high-risk patients,should be urged to follow-up regularly after surgery,so as to achieve early detection,early diagnosis and early treatment of the disease as far as possible.Methods:According to inclusion and exclusion criteria,the study were included total 656 patients who was successfully removed choledocholithiasis through ERCP and gallbladder excision was performed befor or after ERCP in the second affiliated hospital of KunMing medical university since January 2015-June 2020,80%patients(525 cases)were randomly selected as the model group,and the remaining 20%(131 cases)were selected as the validation group,the patients were followed up by outpatient service,hospitalization and telephone call when necessary to know whether the patients had recurrent choledocholithiasis after surgery.Model group was divided into the relapsed group(486 cases)and the non-relapsed group(39 cases).The similarities and differences in general data and clinical data of the two groups were collected and compared.Propensity score matching method was used to take gender,smoking history,drinking history,and hypertension history as predictive variables,and 1:1 ratio was conducted.Patients in the non-recurrence group who were matched to the same number of cases as those in the recurrence group were the control group(n=39),and the comparison was made with those in the recurrence group.The regression coefficients of the significant risk factors for recurrence after matching were included in the equation B0+B1x1+B2X2+····+BNXN,where B0 is a constant,Bn is a regression coefficient,Xn is a risk factor,Xn=1 when the risk factors exist,and Xn=O when the risk factors do not exist.The simplified Logistic regression equation was adopted to uniformly expand the regression coefficient by 2 times,and the method of rounding was adopted to assign the value of the important risk factors.The area under the ROC was calculated through the formula substituted into the model group and the verification group,and the efficiency of the prediction model was tested.SPSS25.0 software package was used for statistical analysis,and P<0.05 was considered statistically significant.Results:1.Among the 525 patients in the model group,39 patients recurred,with a recurrence rate of 7.43%,and 7 patients(17.95%)experienced multiple recurrences in the recurrence group.The cumulative recurrence rates of choledocholithiasis at 1,2,3,4 and 5 years were 1%,4.4%,7.8%,11.7%and 18.2%,.With the passage of time,the recurrence rates showed an increasing trend year by year.2.According to univariate analysis,there were no significant differences in BMI,gender,smoking history,alcohol consumption history,hypertension history,preoperative cholangitis,preoperative serum TC,papillary stenosis,biliary stent drainage,endoscopic mechanical lithotripsy,≥2 ERCP,postoperative pancreatitis,number of stones,and surgical method between the recurrence group and the non-recurrence group.There were statistically significant differences in age,history of diabetes,history of bile duct operation,duodenal diverticulum,diameter of bile duct≥15mm,and diameter of stone≥10mm between the relapsed group and the non-relapsed group.3.Univariate analysis results after preference score matching showed that the other risk factors except diabetes history were consistent with the results before matching.Multivariate analysis showed that duodenal diverticulum(OR=4.197,P=0.012)and stone diameter≥10mm(OR=4.029,P=0.044)were independent risk factors for recurrence of choledocholithiasis.4.According to simple Logistic regression coefficient,the gallbladder excision of ERCP in patients with common bile duct stone recurrence after the most important risk factor for the assignment:age ≥65 1 points,duodenal diverticulum 3 points,bile duct surgery 2 points,bile duct diameter≥ 15 mm 1 point,stone diameter≥ 10mm 3 points,total score<4 is divided into low risk,≥4 scores are in high-risk patients.5.In the model group,the actual recurrence rates in the low and high risk groups are 2.8%and 17.6%,and threshold sensitivity and specificity are 74.4%and 72.0%.In the validation group,the actual recurrence rates in the low and high risk groups are 3.2%and 16.7%,threshold sensitivity and specificity were 66.7%and 75.4%6.The area and 95%CI under the ROC curve of the model group and the validation group were 0.768(0.687-0.850)vs 0.835(0.713-0.957),respectively,indicating that the prediction efficiency of the model was moderate.Conclusion:1.The recurrence rate of choledocholithiasis after ERCP in patients with cholecystectomy was 7.43%(39/486),and 17.95%of patients experienced multiple recurrences in the recurrence people.The cumulative recurrence rates of 1,2,3,4 and 5 years were 1%,4.4%,7.8%,11.7%and 18.2%.2.Age,bile duct operation history,duodenal diverticulum,bile duct diameter≥15mm,stone diameter≥10mm were the important risk factors for choledocholithiasis recurrence after ERCP in patients with cholecystectomy(P<0.05).Duodenal diverticulum(OR=4.197,P=0.012)and stone diameter≥10mm(OR=4.029,P=0.044)were independent risk factors for recurrence of choledocholithiasis.The recurrence probability of patients with duodenal diverticulum was 4 times higher than that of patients without diverticulum,and patients with stone diameter≥10mm were 4 times higher than those with stone diameter<10mm.3.The recurrent causes of choledocholithiasis in patients with cholecystectomy may be basically the same as those in patients with in-situ gallbladder,and the scoring model may also be applicable to patients with in-situ gallbladder.4.The establishment of the scoring model is effective in predicting the recurrence of common bile duct stones in patients with cholecystectomy.