Management of difficult bile duct stones with temporary plastic stent and ursodeoxycholic acid treatment: 5 years of experience

Abstract

Aim: The aim of the study was to investigate the effect of temporary plastic stenting and ursodeoxycholic acid (UDCA) treatment on difficult choledochal stones that cannot be removed by basic ERCP techniques in patients who applied to our clinic with occlusion and underwent endoscopic retrograde cholangiopancreatography (ERCP). Material and Method: Patients were scanned retrospectively using the hospital database. Patients who underwent ERCP due to malignancy, biliary tract injury and benign strictures were excluded from the study. 61 patients who were not successful with basic ERCP techniques such as endoscopic sphincterotomy (EST) and mechanical lithotripsy (ML) were included in the study. 750 mg/day UDCA was given to the patients for three months and plastic stent was applied. After the treatment, ERCP was tried again. Results: Among the patients who underwent stent+UDCA, three (4.9%) patients had perioperative bleeding, one (1.6%) patient had peroperative perforation, four (6.6%) patients had postoperative pancreatitis, and one (1.6%) patient had mortality. The mean hospital stay was 1.96±2.1 days. Post-procedure total bilirubin and direct bilirubin values were observed to be lower than before the procedure (respectively, p<0.001 and p<0.001). The reduction in common bile duct diameter and stone size was found to be statistically significant in patients who underwent two procedures (respectively, p<0.001 and p<0.001). Although the reduction in stone size was statistically significant in patients who underwent three procedures, the decrease in the diameter of the common bile duct was not significant (p=0,090). Conclusion: In our study, temporary plastic stenting and UDCA treatment were shown to be beneficial in common choledochal stones that could not be removed with basic ERCP techniques in the first ERCP session.

Keywords

• Endoscopic retrograde cholangiopancreatography
• choledocholithiasis
• endoscopic sphincterotomy
• ursodeoxycholic acid and bile duct stent

References

1. Freitas ML, Bell RL, Dufy AJ. Choledocholithiasis: evolving standards for diagnosis and management. World J Gastroenterol 2006; 12: 3162–7.
2. Çetinkaya HB, Çay F. Can NLR be Used in discriminating simple and severe cholecystitis in emergency department admission?. Van Med J 2021; 28: 502-6.
3. Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-91.
4. Anderloni A. Difficult common bile duct stones: still “difficult” or just “different”?. Endoscopy 2020; 52: 429-30.
5. Yang J, Peng JY, Chen W. Endoscopic biliary stenting for irretrievable common bile duct stones: Indications, advantages, disadvantages, and follow-up results. Surgeon 2012; 10: 211–7.
6. Ye X, Huai J, Sun X. Efectiveness and safety of biliary stenting in the management of difficult common bile duct stones in elderly patients. Turk J Gastroenterol 2016; 27: 30–6.
7. Lee TH, Han JH, Kim HJ, et al. Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study. Gastrointest Endosc 2011; 74: 96–102.
8. Slattery E, Kale V, Anwar W, Courtney G, Aftab AR. Role of long‐term biliary stenting in choledocholithiasis. Digestive Endoscopy 2013; 25: 440-3.

9. Hormati A, Ghadir M, Sarkeshikian SS, Modarres MP, Rafiei M, Alemi F. Efficacy of common bile duct stenting for large stones. Govaresh 2017; 22: 149-53.
10. Yamamoto R, Tazuma S, Kanno K, et al. Ursodeoxycholic acid after bile duct stone removal and risk factors for recurrence: a randomized trial. J Hepatobiliary Pancreat Surg 2016; 23: 132-6.
11. Johnson KD, Perisetti A, Tharian B, et al. Endoscopic retrograde cholangiopancreatography-related complications and their management strategies: a “scoping” literature review. Dig Dis Sci 2020; 65: 361-75.
12. Park CH, Jung JH, Nam E, et al. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc 2018; 87: 43-57.
13. Ersoz G, Tekesin O, Ozutemiz AO, Gunsar F. Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract. Gastrointest Endosc 2003; 57: 156-9.
14. Hartery K, Lee CS, Doherty GA, et al. Covered self-expanding metal stents for the management of common bile duct stones. Gastrointest Endosc 2017; 85: 181-6.
15. Kogure H, Kawahata S, Mukai T, et al. Multicenter randomized trial of endoscopic papillary large balloon dilation without sphincterotomy versus endoscopic sphincterotomy for removal of bile duct stones: Marvelous trial. Endoscopy 2020; 52: 736-44.
16. Wong JC, Wong MY, Lam KL, Lau JY. Second-generation peroral cholangioscopy and holmium: YAG laser lithotripsy for rescue of impacted biliary stone extraction basket. Gastrointest Endosc 2016; 83: 837-8.
17. Navaneethan U, Hasan MK, Kommaraju K, et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc 2016; 84: 649-55.
18. Kedia P, & Tarnasky PR. Endoscopic management of complex biliary stone disease. Gastrointest Endosc Clinics 2019; 29: 257-75.
19. Di Giorgio P, Manes G, Grimaldi E, et al. Endoscopic plastic stenting for bile duct stones: stent changing on demand or every 3 months. A prospective comparison study. Endoscopy 2013; 45: 1014-7.
20. Han J, Moon JH, Koo HC, et al. Effect of biliary stenting combined with ursodeoxycholic acid and terpene treatment on retained common bile duct stones in elderly patients: a multicenter study. ACG 2009; 104: 2418-21.
21. Hormati A, Ghadir MR, Sarkeshikian SS, et al. Adding ursodeoxycholic acid to the endoscopic treatment and common bile duct stenting for large and multiple biliary stones: Will it improve the outcomes?. BMC Gastroenterol 2020; 20: 1-5.
22. Ödemiş B, Kuzu UB, Öztaş E, et al. Endoscopic management of the difficult bile duct stones: a single tertiary center experience. Gastroenterol Res Pract 2016.
23. Katsinelos P, Kountouras J, Paroutoglou G, Chatzimavroudis G, Zavos C. Combination of endoprostheses and oral ursodeoxycholic acid or placebo in the treatment of difficult to extract common bile duct stones. Dig Liver Dis 2008; 40: 453-9.
24. Slattery E, Kale V, Anwar W, Courtney G, Aftab AR. Role of long‐term biliary stenting in choledocholithiasis. Digestive Endoscopy 2013; 25: 440-3.
25. Hofmann AF. Medical treatment of cholesterol gallstones by bile desaturating agents. Hepatology 1984; 4: 199-208.
26. Banerjee N, Hilden K, Baron TH, Adler DG. Endoscopic biliary sphincterotomy is not required for transpapillary SEMS placement for biliary obstruction. Dig Dis Sci 2011; 56: 591-5.
27. Çay F, Girgin M. Is laparoscopic cholecystectomy safe in acute cholecystitis?. Health Sci J Adıyaman Universty 2017; 3: 487-95.