KEY FACTORS LEADING TO INCOMPLETE BILIARY STONES CLEARANCE DURING THEIR FIRST ERCP IN PATIENTS WITH NAïVE PAPILLA

Aims ERCP is currently the standard of care for the management of bile duct stones. The clearance of bile duct stones has improved with techniques as endoscopic papillary large balloon dilation (PLBD) or the novel intraductal therapies based on peroral cholangioscopy (POC), but reports about large stones clearance scarce.

Methods Prospective enrolment of 397 consecutive patients with suspicion of intraductal biliary stones in two University Hospitals. Analysis of the factors influencing the bile duct stones’ clearance failure during the first ERCP in naïve papilla patients. Primary outcome: complete ductal clearance (CC) on first attempt. Secondary outcome: CC according to demography, and to patient and technical features.

Results 397 consecutive, papilla-näive patients elected for ERCP(56.4% female; 68.2% >69 years; 55,5% ASA-II-III). Global CC: 87.4%; incomplete removal: 5,0%; clearance failure: 7.5%. Univariant model: age, gender, ASA, indication or endoscopist experience did not reach significant differences (p< 0.05). Altered anatomy (p< 0.03), post-ERCP pancreatitis (p< 0.03), intraprocedural incidents (p=0.0005), anticoagulant disorders (p< 0.03) or drugs (p< 0.01), non-routine techniques (pre-cut, PLBD mechanic lithotricia, or POC (p< 0.0001) lead to CC failure. Multiple stones was a statistical significant factor for failed retrieval (p< 0.005). Only 67.5% of stones sized 19 mm or more were removed, as compare to a 93,7% CC in small stones (p< 0.0001). Multivariant analysis showed only significance for stone size, with an area under de curve ROC=0.637.

Conclusions

1. In our cohort, the main cause of failed CC of biliary stones was a stone size larger than 18 mm.

2. Other features that may influence were: > 3 choledocolithiasis, intraprocedural incidents, anticoagulants and modified anatomy.

3. The most frequent use of LBPD and the implementation of electrohydraulic or intraductal lithotripsy might help to improve the complete clearance rate, during the first ERCP, especially in patients with larger stones.