| Objective: In 2017,the Biliary Surgery Section of the Surgical Branch of the Chinese Medical Association formulated the "Guideline for the Diagnosis and Treatment for Biliary Dilatation" for the first time,which provided guiding opinions on the definition,diagnosis,classification and treatment of BD.As one of the causes of BD,pancreaticobiliary maljunction is closely related to the diagnosis and treatment of BD,and the understanding of PBM should be strengthened.PBM is a rare congenital disease,and there are no relevant studies on the distribution of PBM in patients with extrahepatic bile duct stones and gallstones.In this study,the distribution of PBM in patients with cholecystolithiasis and extrahepatic bile duct stones in Shengjing Hospital of China Medical University was analyzed.And the distribution characteristics of age and stone location in various types of PBM were analyzed,hoping to provide the distribution characteristics of PBM in patients with extrahepatic bile duct stones at home and improve doctors’ attention to PBM in clinical practice.Extrahepatic duct stone is a common digestive system disease,despite of various treatment including endoscopic and surgical measures,its recurrence is still common.Common factors associated with recurrence of extrahepatic bile duct stones in previous studies include bile duct anatomical variation(eg,juxtapapillary duodenal diverticula),dynamics(biliary duct dilatation,sharp angle,and number of stones),metabolism(advanced age and hypothyroidism),and bacterial infection(Enterobacter and Helicobacter pylori).ERCP is an important treatment for common bile duct stones,but the recurrence rate of stones after ERCP is high.In this study,the risk factors for recurrence of extrahepatic bile duct stones in our center were analyzed,including PBM and ERCP.It is helpful to screen patients with high risk of recurrence and enhance the follow-up of these patients and the prevention of stone recurrence.The selection of surgical methods for extrahepatic bile duct stones was also discussed.Although knowing about the risk factors for extrahepatic bile duct stones can help to screen patients at higher risk for recurrence,a systematic and quantitative assessment of individual patient recurrence risk cannot be accessed.In the era of advocating precise medicine,the establishment of a predictive model can assess the risk of stone recurrence for each individual patient,thus guide treatment and follow-up,which is of great significance for the treatment and management of patients with extrahepatic bile duct stones.Methods: PartⅠ:We collected the data of gallstone and/or extrahepatic duct stone patients in Shengjing Hospital of China Medical University from 10-01-2011 to 9-30-2018.The general data of the patients who met the inclusion criteria were collected,and the MRCP images were read to determine whether the patients had PBM.Then the distribution of PBM in patients with gallstones,extrahepatic bile duct stones,and gallstones complicated with extrahepatic bile duct stones,as well as the characteristics of various types of PBM.PartⅡ:We selected patients with extrahepatic bile duct stones who were admitted to the Department of General Surgery of Shengjing Hospital(Nanhu district)from January 2016 to December 2018.The determination of the recurrence of bile duct stones was through case data in the hospital information system and telephone follow-up methods.Eligible patients were selected and divided into recurrence group and control group.The patients’ age,gender,weight,prevalence of hypertension and diabetes,history of drinking,bile duct diameter,surgical history,number of stones,gallbladder status and JPD were counted.The presence of pancreaticobiliary maljunction was determined by MRCP,ERCP or T-tube angiography and the common bile duct angle was measured.First,the factors with statistical significance were screened by univariate analysis,and these factors were included in the multivariate Logistic regression analysis.Cutoff values for risk factors belonging to quantitative data were calculated with ROC curves.Part Ⅲ: The data of patients with extrahepatic bile duct stones in Nanhu District and Huaxiang District of Shengjing Hospital was divided into development and validation cohort.The patients’ clinicopathological characters were recorded.The least absolute shrinkage and selection operator(LASSO)binary logistic regression model was used for data dimension reduction and feature selection,then multivariable logistic regression analysis was used to develop the predictive model.The performance of the predictive model was assessed in regards to discrimination,calibration,and clinical usefulness.Outcomes: 1.Distribution of PBM in patients with cholelithiasis: PBM accounted for 1.0% of total cases,0.7% of cases with cholecystolithiasis,2.5% of isolated extrahepatic bile duct stones,and 1.4% of cases accompanied with both gallstones and extrahepatic bile duct stones.There was a statistically significant difference in the incidence of PBM among patients with different stone sites(P<0.001).The age of cholelithiasis patients with PBM was significantly lower than that of patients without PBM,and the proportion of women was higher in patients with PBM and cholelithiasis.The proportions of PBM and non-PBM in the patients with gallbladder,extrahepatic bile duct,gallbladder and extrahepatic bile duct stones were 48.1%,25.9%,25.9% and 71.4%,10.3% and 18.3%,respectively,and the differences were statistically significant(P< 0.001).The age of PBM patients with biliary dilatation was 41.4±14.7 years old,and the average age of PBM patients without biliary dilatation was 54.4±17.4 years old,the former was significantly lower than the latter.C-P duct type accounted for 76.2% of bile duct dilated PBM,while non-dilated PBM were all P-C type.C-P type PBM patients with cholelithiasis were younger,while P-C PBM patients had more stones in the gallbladder.2.Risk factors of extrahepatic bile duct stone recurrence: After univariate analysis,only the patients’ age,PBM,JPD,ERCP history and common bile duct diameter met the inclusion criteria(P<0.1).Incorporating the above factors into multivariate Logistic regression analysis,it was finally concluded that PBM(OR=11.728,P=0.038),JPD OR=2.37,P=0.009),history of ERCP(OR=1.913,P=0.029)and common bile duct diameter(OR=1.191,P<0.001)were the independent risk factors for recurrence of extrahepatic bile duct stones.Common bile duct diameter of 14 mm was the cut-off value according to ROC curve,and the OR value of common bile duct diameter>14mm was 5.49(P<0.001).3.Predictors of this model included PBM,JPD,ERCP history and common bile duct diameter.The scores of the variables are: JPD=1,PBM=50,ERCP history=13;CBD diameter ≤4mm is 0,and adds 2 points as CBD diameter gets every 2mm wider.Total score acceding 52 indicated that the patient had high risk of stone recurrence.For the validation cohort,the model showed good discrimination with an AUROC of 0.74(P<0.001)and good calibration(Unreliability test,P=0.921).Decision curve analysis demonstrated that the model was also clinical useful.Conclusions: Pancreaticobiliary maljunction occurs approximately 1% in patients with cholelithiasis,which is higher than that of PBM in the general population.The proportion of PBM was higher in cases of extrahepatic bile duct stones.Cholelithiasis patients with PBM had a higher proportion of bile duct stones than those without PBM.Contrary to previous findings,there was no significant difference in the site of stone formation between dilated and non-dilated PBMs.Cholecystectomy should be performed in patients with nondilated PBM,while biliary dilatation can be diagnosed in patients with bile duct dilated PBM and extrahepatic bile duct resection and Roux-en-Y choledochojejunostomy.PBM,JPD,ERCP history and common bile duct diameter are independent risk factors for the recurrence of extrahepatic bile duct stones.For patients with recurrent extrahepatic bile duct stones and a common bile duct diameter greater than 14 mm,choledochojejunostomy is recommended to reduce recurrence of stones.This study provided a predictive model for recurrence of extrahepatic bile duct stones,which can help clinicians to assess the risk of extrahepatic bile duct stone recurrence.PBM,JPD,ERCP history and common bile duct diameter are effective predictors.The model can provide a quantitive and individualized scale to predict the risk if gallstone occurrence. |
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