Advertisement

Natural history of asymptomatic bile duct stones and association of endoscopic treatment with clinical outcomes

  • Ryunosuke Hakuta
  • Tsuyoshi Hamada
  • Yousuke NakaiEmail author
  • Hiroki Oyama
  • Sachiko Kanai
  • Tatsunori Suzuki
  • Tatsuya Sato
  • Kazunaga Ishigaki
  • Kei Saito
  • Tomotaka Saito
  • Naminatsu Takahara
  • Suguru Mizuno
  • Hirofumi Kogure
  • Takeyuki Watadani
  • Takeshi Tsujino
  • Minoru Tada
  • Osamu Abe
  • Hiroyuki Isayama
  • Kazuhiko Koike
Original Article—Liver, Pancreas, and Biliary Tract
  • 217 Downloads

Abstract

Background

Due to increasing opportunities for abdominal imaging studies, bile duct stones are occasionally diagnosed without any symptoms. However, there has been no consensus on the management of asymptomatic bile duct stones. We conducted a retrospective longitudinal cohort study to investigate the natural history of asymptomatic bile duct stones and clinical outcomes according to the timing of endoscopic removal.

Methods

We identified consecutive patients who were diagnosed with asymptomatic common bile duct stones and categorized into those who were followed up with stones in situ (wait-and-see group) and those who received early endoscopic stone removal (intervention group). Cumulative incidence functions of biliary complications were estimated and compared between the groups.

Results

We included 191 patients (114 patients in the wait-and-see group and 77 patients in the intervention group). In the wait-and-see group, the cumulative incidence of biliary complications was 6.1% at 1 year, 11% at 3 years, and 17% at 5 years. Asymptomatic disappearance of stones was observed in 22 patients (19%). Procedure-related adverse events of early endoscopic stone removal of asymptomatic stones were observed in 25 (32%) patients including 4 (5.2%) with severe pancreatitis. The cumulative incidence function of biliary complications did not differ by treatment strategies (P = 0.55).

Conclusions

Biliary complications occurred in a substantial proportion of patients with asymptomatic bile duct stones, but early endoscopic removal appeared to have little effect on the prevention of further biliary complications. Given the risk of procedure-related pancreatitis, the wait-and-see strategy may become a management option of asymptomatic stones.

Keywords

Cholangitis Choledocholithiasis Endoscopic retrograde cholangiopancreatography Gallstone Pancreatitis 

Notes

Author contributions

RH, TH, and YN: conception and design of the study, analysis, and interpretation of the data, and drafting of the article. HO, SK, TS, TS, KI, KS, TS, NT, SM, HK, TW, TT, MT, OA, HI, and KK: critical revision of the article for important intellectual content. All authors: final approval of the article.

Compliance with ethical standards

Conflict of interest

We declare that we have no conflicts of interest.

Supplementary material

535_2019_1612_MOESM1_ESM.docx (54 kb)
Supplementary file1 (DOCX 53 kb)
535_2019_1612_MOESM2_ESM.tif (1.5 mb)
Supplementary file2 (tif 1498 kb)

References

  1. 1.
    Gigot J, Leese T, Dereme T, et al. Acute cholangitis. Multicariate analysis of risk factors. Ann Surg. 1989;209:435–8.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Tazuma S, Unno M, Igarashi Y, et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017;52:276–300.CrossRefPubMedGoogle Scholar
  3. 3.
    Williams E, Beckingham I, El Sayed G, et al. Updated guideline on the management of common bile duct stones (CBDS). Gut. 2017;66:765–82.CrossRefPubMedGoogle Scholar
  4. 4.
    Committee ASOP, Maple JT, Ikenberry SO, et al. The role of endoscopy in the management of choledocholithiasis. Gastrointest Endosc. 2011;74:731–44.CrossRefGoogle Scholar
  5. 5.
    Kondo S, Isayama H, Akahane M, et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Eur J Radiol. 2005;54:271–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Freeman ML. Adverse outcomes of ERCP. Gastrointest Endosc. 2002;56:S273–S282282.CrossRefPubMedGoogle Scholar
  7. 7.
    Cotton PB, Garrow DA, Gallagher J, et al. Risk factors for complications after ERCP: a multivariate analysis of 11,497 procedures over 12 years. Gastrointest Endosc. 2009;70:80–8.CrossRefPubMedGoogle Scholar
  8. 8.
    Disario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology. 2004;127:1291–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Saito H, Kakuma T, Kadono Y, et al. Increased risk and severity of ERCP-related complications associated with asymptomatic common bile duct stones. Endosc Int Open. 2017;5:E809–E817817.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Kim SB, Kim KH, Kim TN. Comparison of outcomes and complications of endoscopic common bile duct stone removal between asymptomatic and symptomatic patients. Dig Dis Sci. 2016;61:1172–7.CrossRefPubMedGoogle Scholar
  11. 11.
    Cotton PB, Eisen GM, Aabakken L, et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010;71:446–54.CrossRefGoogle Scholar
  12. 12.
    Miura F, Okamoto K, Takada T, et al. Tokyo guidelines 2018: initial management of acute biliary infection and flowchart for acute cholangitis. J Hepatobiliary Pancreat Sci. 2018;25:31–40.CrossRefPubMedGoogle Scholar
  13. 13.
    Kiriyama S, Kozaka K, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:17–30.CrossRefPubMedGoogle Scholar
  14. 14.
    Yokoe M, Hata J, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018;25:41–544.CrossRefPubMedGoogle Scholar
  15. 15.
    Nakai Y, Kogure H, Yamada A, et al. Endoscopic management of bile duct stones in patients with surgically altered anatomy. Dig Endosc. 2018;30(Suppl 1):67–74.CrossRefPubMedGoogle Scholar
  16. 16.
    Hakuta R, Hamada T, Nakai Y, et al. Multicenter retrospective and comparative study of 5-minute versus 15-second endoscopic papillary balloon dilation for removal of bile duct stones. Endosc Int Open. 2017;5:E1027–E10341034.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Takahara N, Isayama H, Sasaki T, et al. Endoscopic papillary balloon dilation for bile duct stones in patients on hemodialysis. J Gastroenterol. 2012;47:918–23.CrossRefPubMedGoogle Scholar
  18. 18.
    Kawabe T, Komatsu Y, Tada M, et al. Endoscopic papillary balloon dilation in cirrhotic patients: removal of common bile duct stones without sphincterotomy. Endoscopy. 1996;28:694–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Itoi T, Ryozawa S, Katanuma A, et al. Japan Gastroenterological Endoscopy Society guidelines for endoscopic papillary large balloon dilation. Dig Endosc. 2018;30:293–309.CrossRefPubMedGoogle Scholar
  20. 20.
    Hakuta R, Kawahata S, Kogure H, et al. Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: a propensity-matched analysis. Dig Endosc. 2019;31:59–68.CrossRefPubMedGoogle Scholar
  21. 21.
    Ozawa N, Yasuda I, Doi S, et al. Prospective randomized study of endoscopic biliary stone extraction using either a basket or a balloon catheter: the BasketBall study. J Gastroenterol. 2017;52:623–30.CrossRefPubMedGoogle Scholar
  22. 22.
    Hamada T, Nakai Y, Isayama H, et al. Estimation and comparison of cumulative incidences of biliary self-expandable metallic stent dysfunction accounting for competing risks. Dig Endosc. 2014;26:270–5.CrossRefPubMedGoogle Scholar
  23. 23.
    Kanda Y. Investigation of the freely available easy-to-use software 'EZR' for medical statistics. Bone Marrow Transplant. 2013;48:452–8.CrossRefGoogle Scholar
  24. 24.
    Elmunzer BJ. Reducing the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis. Dig Endosc. 2017;29:749–57.CrossRefPubMedGoogle Scholar
  25. 25.
    Joyce W, Keane R, Burke G, et al. Identification of bile duct stones in patients undergoing laparoscopic cholecystectomy. Br J Surg. 1991;78:1174–6.CrossRefPubMedGoogle Scholar
  26. 26.
    Moller M, Gustafsson U, Rasmussen F, et al. Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA Surg. 2014;149:1008–133.CrossRefPubMedGoogle Scholar
  27. 27.
    Ammori BJ, Birbas K, Davides D, et al. Routine vs "on demand" postoperative ERCP for small bile duct calculi detected at intraoperative cholangiography. Clinical evaluation and cost analysis. Surg Endosc. 2000;14:1123–6.CrossRefPubMedGoogle Scholar
  28. 28.
    Caddy G, Kirby J, Kirk S, et al. Natural history of asymptomatic bile duct stones at time of cholecystectomy. Ulster Med J. 2005;74:108–12.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Collins C, Maguire D, Ireland A, et al. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg. 2004;239:28–33.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Yun SP, Seo HI. Clinical aspects of bile culture in patients undergoing laparoscopic cholecystectomy. Medicine (Baltimore). 2018;97:e11234.CrossRefGoogle Scholar
  31. 31.
    Mazaki T, Mado K, Masuda H, et al. Prophylactic pancreatic stent placement and post-ERCP pancreatitis: an updated meta-analysis. J Gastroenterol. 2014;49:343–55.CrossRefPubMedGoogle Scholar
  32. 32.
    Elmunzer BJ, Scheiman JM, Lehman GA, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366:1414–22.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Freeman ML, DiSario JA, Nelson DB, et al. Risk factors for post-ERCP pancreatitis: a prospective, multicenter study. Gastrointest Endosc. 2001;54:425–34.CrossRefPubMedGoogle Scholar
  34. 34.
    Nakai Y, Isayama H, Tsujino T, et al. Cholecystectomy after endoscopic papillary balloon dilation for bile duct stones reduced late biliary complications: a propensity score-based cohort analysis. Surg Endosc. 2016;30:3014–20.CrossRefPubMedGoogle Scholar
  35. 35.
    Tsujino T, Kawabe T, Komatsu Y, et al. Endoscopic papillary balloon dilation for bile duct stone: immediate and long-term outcomes in 1000 patients. Clin Gastroenterol Hepatol. 2007;5:130–7.CrossRefPubMedGoogle Scholar

Copyright information

© Japanese Society of Gastroenterology 2019

Authors and Affiliations

  • Ryunosuke Hakuta
    • 1
  • Tsuyoshi Hamada
    • 1
  • Yousuke Nakai
    • 1
    Email author
  • Hiroki Oyama
    • 1
  • Sachiko Kanai
    • 1
  • Tatsunori Suzuki
    • 1
  • Tatsuya Sato
    • 1
  • Kazunaga Ishigaki
    • 1
  • Kei Saito
    • 1
  • Tomotaka Saito
    • 1
  • Naminatsu Takahara
    • 1
  • Suguru Mizuno
    • 1
  • Hirofumi Kogure
    • 1
  • Takeyuki Watadani
    • 2
  • Takeshi Tsujino
    • 1
  • Minoru Tada
    • 1
  • Osamu Abe
    • 2
  • Hiroyuki Isayama
    • 1
    • 3
  • Kazuhiko Koike
    • 1
  1. 1.Department of Gastroenterology, Graduate School of MedicineThe University of TokyoTokyoJapan
  2. 2.Department of Radiology, Graduate School of MedicineThe University of TokyoTokyoJapan
  3. 3.Department of Gastroenterology, Graduate School of MedicineJuntendo UniversityTokyoJapan

Personalised recommendations