The Value Of EUS On The Recurrence Rate Of Common Bile Duct Stones After ERCP

【Objectives】Endoscopic retrograde cholangiopancreatography(ERCP)is currently the first choice for the treatment of common bile duct(CBD)stones.However,small stones are easily missed during surgery,and the recurrence rate of stones after ERCP is still high.Endoscopic ultrasound(EUS)has high sensitivity to tiny stones and can make up for this shortcoming of ERCP.EUS examination is performed immediately after ERCP to observe the presence of remnant biliary stones or sludge,and at the same time assess the size of remnant biliary stones or sludge,and perform ERCP twice as soon as possible to reduce the recurrence rate of CBD stones.This study aimed to explore the incidence of remnant biliary stones or sludge after the removal of CBD stones,related risk factors,and the risk factors for the recurrence of stones,and the effect of EUS on reducing the recurrence rate of CBD stones after ERCP.【Methods】A prospective study enrolling a consecutive series of patients who underwent ERCP for CBD stones removal was performed between September 2018 and September 2019 in our hospital.Following confirmation of complete CBD stones removal by the operator,EUS was performed to determine whether biliary stones or sludge remained.If there were biliary stones or sludge remained,then measured the size of the stones.If they were larger than 3mm,performed the second ERCP on the same platform.Patients were subsequently followed up at a regular interval of 3–6months for one year until September 2020.Then we could investigate whether the stones had recurred.If the stones had recured within one year,the followup would be terminated.The group called cleared stones included the patients with had no biliary stones or sludge and those with biliary stones or sludge greater than 3 mm who had underwent a second ERCP operation.In the uncleared group,the EUS examination showed that the biliary stones or sludge were less than 3mm.Compared the recurrence rate of stones of the two groups.According to the presence or absence of biliary stones or sludge,they were divided into two groups.According to whether the stones had recurred,they were also divided into two groups.Univariate and multivariate logistic/COX analysis were performed on the two pairs of groups respectively to observe the risk factors of remnant biliary stones or sludge and the recurrence of CBD stones and the effect of EUS on reducing the recurrence rate of CBD stones after operation.【Results】A total of 80 patients were enrolled.The presence of remnant biliary stones or sludge after ERCP was confirmed in 36.25%(29/80).During the followup period,the overall recurrence rate was 23.75%(19/80).Among them,the recurrence rate of the stone cleared group was 16.39%(10/61),and the recurrence rate of the uncleared stone group was 47.37%(9/19).The recurrence rate of patients with biliary stones or sludge after the EUS examination was 30%(3/10)for patients after the second ERCP operation,and 47.37%(9/19)for biliary stones or sludge who did not undergo the second ERCP operation.Univariate analysis of basic data of patients with or without remnant biliary stones or sludge showed that the number of ERCP、angulated distal CBD had an effect on the risk factors of remnant biliary stones or sludge.Age、gender、body mass index(BMI)、previous cholecystectomy、previous ERCP operation、periampullary duodenal diverticulum、the color of stones、diameter of CBD、endoscopic papillary large balloon dilatation(EPLBD)、lithotripsy had no effect on the risk factors of remnant biliary stones or sludge.It showed that angulated distal CBD was the sole factor associated with remnant biliary stones or sludge by multivariate logistic analysis(OR=0.625,95% CI:0.4910.796,P<0.001).According to whether the stones had recurred,they were also divided into two group.Univariate analysis showed that remnant biliary stones or sludge had an effect on the risk factors of the recurrence of CBD stones.Gender、age、BMI、diameter of CBD、angulated distal CBD 、previous cholecystectomy、periampullary duodenal diverticulum、previous ERCP operation、the number of ERCP、the color of stones、EPLBD、lithotripsy had no effect on the risk factors of the recurrence of CBD stones.The risk of recurrence in the remnant biliary stones or sludge group was 3.578 times that of the none groups(95% CI:1.4079.096).The recurrence of CBD stones was predicted by remnant biliary stones or sludge in multivariate COX analysis(HR=8.822,95% CI:1.78743.551,P=0.008).【Conclusions】Angulated distal CBD was associated with remnant biliary stones or sludge after ERCP.The smaller the angulation,the higher the incidence of remnant biliary stones or sludge.Remnant biliary stones or sludge is a powerful predictor of CBD stones recurrence.EUS examination after CBD stones removal by ERCP could reduce the recurrence rate of CBD stones.Therefore,if we find that the angulated distal CBD has a small angulation during the ERCP operation,we will consider further EUS examination to see if there are remnant biliary stones or sludge.According to the size of the stones,consider a second ERCP operation.