Factors Significantly Contributing to a Failed Conventional Endoscopic Stone Clearance in Patients with “Difficult” Choledecholithiasis: A Single-Center Experience
The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm. 1. Introduction Common bile duct (CBD) lithiasis is present in 7%–12% of patients with cholecystolithiasis and represents a well-established indication for endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and basket or balloon stone extraction (SE) techniques [1]. Bile duct stones vary in size ranging from rather small (1-2？mm) to very large (>3？cm) [2]. The vast majority of them (85%–95%) can be removed with the use of conventional endoscopic techniques [3, 4]. Balloon dilatation following endoscopic sphincterotomy is an easy to use alternative for difficult to extract BDS with an acceptable safety profile [5]. However, despite the refinements in endoscopic removal of BDS, complete SE can be occasionally difficult posing an endoscopic challenge. Extraction of BDS can be difficult for anatomic alteration and stone, duct, and patients’ factors [6–9]. The size and number of BDS are major determinants of their resistance to extraction. Among other important factors, the acute distal angulation of the CBD and the shorter length of its distal CBD “arm,” the altered postsurgical anatomy, and the firmness and diameter of BDS relative to the width of the distal CBD [6–9] are included. Failure of SE exposes the patients to a
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