Effect Of Gallbladder Intervention Strategy On Recurrence Of Choledocholithiasis After ERCP

【Objective】It aims to explore the probability and related risk factors of common bile duct stones’ recurrence in patients with choledocholithiasis under different gallbladder intervention strategies after ERCP,and to further clarify the role of gallbladder in choledocholithiasis recurrence.【Methods】A total of 562 patients with choledocholithiasis were treated with ERCP in our hospital for the first time from January 2015 to January 2018.After excluding patients with biliary tract tumor or stone residue after ERCP and without data or follow-up,a total of 355 patients were followed up for 3 years,including 75 cases of recurrence and280 cases of non-recurrence.The total recurrence rate was 21.13%.355 patients were divided into three groups according to the different intervention strategies for gallbladder.The first group was patients who underwent ERCP lithotomy for choledocholithiasis and underwent cholecystectomy after operation(n=102),the second group was patients who underwent ERCP lithotomy for choledocholithiasis but retained the gallbladder after operation(n=198),and the third group is the patients who underwent cholecystectomy for gallbladder stones and new common bile duct stones after the operation(n=55).The clinical data of recurrent and non-recurrent patients in each group were analyzed.The metrological data in accordance with normal distribution were expressed as mean ±standard deviation,while those with non-normal distribution were expressed as median(first quartile,third quartile).The metrological data were analyzed by t-test or u-test,and counting data were analyzed by chi-square test or Fisher exact probability analysis.Furthermore,the statistically significant indexes were analyzed by multivariate Logistic regression analysis,and the independent risk factors of choledocholithiasis recurrence after ERCP under different intervention strategies for gallbladder were screened,and the recurrence time of choledocholithiasis under different intervention strategies for gallbladder was analyzed by Kaplan-Meier curve.【Results】A total of 75 patients were confirmed to have recurrent choledocholithiasis during the 3-year follow-up period.The recurrence rate was 11.76%(12/102)in the ERCP lithotomy + postoperative cholecystectomy group,19.70%(39/198)in the ERCP lithotomy + postoperative gallbladder preservation group,and 43.64%(24/55)in the previous cholecystectomy + ERCP lithotomy group.In multivariate analysis,body mass index(BMI)was the common risk factor for recurrence among the three groups.In addition,diabetes and the mode of operation were the independent risk factors for choledocholithiasis recurrence in ERCP lithotomy + postoperative cholecystectomy group(p=0.030,p=0.001).Age,common bile duct diameter and the number of choledocholithiasis were the independent risk factors for choledocholithiasis recurrence in ERCP lithotomy + postoperative gallbladder preservation group(p=0.014,p=0.001,p=0.003,p=0.013).In the previous cholecystectomy + ERCP lithotomy group,the age was the independent risk factors for the recurrence of choledocholithiasis(p<0.001).There was significant difference in recurrence rate among the three groups.There was no significant difference in recurrence rate between the ERCP lithotomy + postoperative gallbladder preservation group and the ERCP lithotomy + postoperative gallbladder preservation group,while there was significant difference in the previous cholecystectomy + ERCP lithotomy group compared with the former two groups.The median recurrence time of choledocholithiasis in the three groups was 22 months,18 months and 20 months respectively.【Conclusion】The recurrence rate of choledocholithiasis after ERCP is different in various gallbladder states,and there is no significant difference between the ERCP lithotomy +cholecystectomy group and the ERCP lithotomy + postoperative gallbladder preservation group,indicating that gallbladder preservation after ERCP does not increase the probability of recurrence of choledocholithiasis.The recurrence rate in the previous cholecystectomy + ERCP lithotomy group is significantly higher,indicating early cholecystectomy could not reduce the incidence of choledocholithiasis,and the stone recurrence rate increased significantly after ERCP lithotomy for choledocholithiasis,indicating that the existence of gallbladder has a potential preventive effect on the formation of choledocholithiasis.The median recurrence time of choledocholithiasis in the three groups was 22 months,18 months and 20 months respectively,indicating that the median time of recurrence of choledocholithiasis in patients with preservation of gallbladder after ERCP lithotomy was shorter than that in patients with cholecystectomy,but with the extension of follow-up time,there was no significant difference in the overall recurrence rate between the patients who underwent cholecystectomy and that preserved gallbladder after cholecystectomy,indicating that cholecystectomy could not reduce the recurrence of choledocholithiasis.BMI is a common independent risk factor for the recurrence of choledocholithiasis in the three groups.For patients with choledocholithiasis after choledocholithotomy with ERCP,EST combined with EPBD will increase the probability of recurrence of choledocholithiasis.For patients with gallbladder retention after ERCP lithotomy,age,diameter of common bile duct and number of choledocholithiasis are independent risk factors for recurrence of choledocholithiasis.And for patients with choledocholithiasis who underwent cholecystectomy,age is a risk factor for recurrence of choledocholithiasis.