Impact of Gallbladder Status on the Outcome in Patients with Retained Bile Duct Stones Treated with Extracorporeal Shockwave Lithotripsy

Background and Study Aims: The use of endoscopic therapy in combination with lithotripsy techniques has become increasingly common in patients with complicated common bile duct stones. In many units, although this is controversial, cholecystectomy is then performed, because of possible subsequent cholecystitis and recurrence of choledocholithiasis. The aim of this study was to investigate whether gallbladder status influences the long-term outcome in patients after extracorporeal shockwave lithotripsy (ESWL) of common bile duct stones.
Patients and Methods: Recruited for the study were 120 patients with an average age of 68 years (range 28 - 86). They were selected from 137 consecutive patients who presented to our department between January 1989 and June 1996 with complicated common bile duct stones, and in whom ESWL was necessary to achieve complete clearance of stones. Follow-up data were obtained from the patients and their general practitioners.
Results: The mean duration of follow-up was 4 years (range 3 - 9). A total of 37 patients had their gallbladder in situ (group A), while 83 had undergone cholecystectomy. Of these 83 patients, 27 had had a cholecystectomy after ESWL (group B), whereas 56 patients had already had the gallbladder removed when choledocholithiasis was diagnosed (group C). During follow-up, 36 patients (30 %) experienced some biliary symptoms. There were no significant differences in the incidence of recurrent biliary symptoms between the three groups. Re-exploration of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) revealed 28 cases of recurrent bile duct stones. Recurrence developed more often in groups B and C, who had undergone cholecystectomy, without reaching statistical significance (P = 0.077). In patients with an intact gallbladder (group A), there was no difference in the rate of recurrent biliary symptoms or stones between the patients with or without cholecystolithiasis. Operations were necessary in 28 patients; in only ten was this for biliary reasons.
Conclusion: The intact gallbladder is not a risk factor for recurrent biliary complications after ESWL of common bile duct stones; therefore, as far as patients with complicated bile duct stones which require additional lithotripsy techniques are concerned, elective cholecystectomy after endoscopic clearance of the bile duct no longer seems appropriate.

References

• 1 Adamek H E, Maier M, Jakobs R. et al . Management of retained bile duct stones: a prospective open trial comparing extracorporeal and intracorporeal lithotripsy.  Gastrointest Endosc. 1996;  44 40-47
• 2 Rösch W, Riemann J F, Lux G, Lindner H G. Long-term follow-up after endoscopic sphincterotomy.  Endoscopy. 1981;  13 152-153
• 3 Tham T CK, Kennedy R, O’Connor F A. Early complications and mean 8-year follow-up after endoscopic sphincterotomy in young fit patients.  Eur J Gastroenterol Hepatol. 1994;  6 621-624
• 4 Bergmann J JGHM, van der Mey S, Rauws E AJ. et al . Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age.  Gastrointest Endosc. 1996;  44 643-649
• 5 Hammarström L E, Homin T, Stridbeck H. Endoscopic treatment of bile duct calculi in patients with gallbladder in situ: long-term outcome and factors predictive of recurrent symptoms.  Scand J Gastroenterol. 1996;  31 294-301
• 6 Bergmann J JGHM, van Berkel A M, Groen A K. Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy.  Gastrointest Endosc. 1997;  45 400-405
• 7 Karlson B M, Ekbom A, Arvidsson D. Population-based study of cancer risk and relative survival following sphincterotomy for stones in the common bile duct.  Br J Surg. 1997;  84 1235-1238
• 8 Wojtun S, Gil J, Gietka W, Gil M. Endoscopic sphincterotomy for choledocholithiasis: a prospective single-center study on the short-term and long-term treatment results in 483 patients.  Endoscopy. 1997;  29 258-265
• 9 Ikeda S, Tanaka M, Matsumo S. et al . Endoscopic sphincterotomy: long-term results in 408 patients with complete follow-up.  Endoscopy. 1988;  20 13-17
• 10 Pereira-Lima J C, Jakobs R, Winter U H. et al . Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis: multivariate analysis of prognostic factors for the recurrence of biliary symptoms.  Gastrointest Endosc. 1998;  48 457-464
• 11 Meyenberger C, Meierhofer U, Michel-Harder C. et al . Long-term follow-up after treatment of common bile duct stones by extracorporeal shock-wave lithotripsy.  Endoscopy. 1996;  28 411-417
• 12 Hawes R H, Cotton P B, Vallon A G. Follow-up 6 to 11 years after duodenoscopic sphincterotomy for stones in patients with prior cholecystectomy.  Gastroenterology. 1990;  98 1008-1012
• 13 Lai K H, Lin L F, Lo G H. et al . Does cholecystectomy after endoscopic sphincterotomy prevent the recurrence of biliary complications ?.  Gastrointest Endosc. 1999;  49 483-487
• 14 Weber J, Adamek H E, Riemann J F. Extracorporeal piezoelectric lithotripsy for retained bile duct stones.  Endoscopy. 1992;  24 239-243
• 15 Prat F, Malak N A, Pelletier G. et al . Biliary symptoms and complications more than 8 years after endoscopic sphincterotomy for choledocholithiasis.  Gastroenterology. 1996;  110 894-899
• 16 Saito M, Tsuyuguchi T, Yamaguchi T. et al . Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis.  Gastrointest Endosc. 2000;  51 540-545
• 17 Escourrou J, Cordova J A, Lazorthes F. et al . Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gall bladder in situ.  Gut. 1984;  25 598-602
• 18 Yi S Y. Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones.  J Gastroenterol Hepatol. 2000;  15 661-664
• 19 Riemann J F, Gierth K, Lux G, Altendorf A. Gallbladder with stones in situ - a risk factor after endoscopic papillotomy? [In German.]  Z Gastroenterol. 1984;  22 188-193
• 20 Keulemanns Y CA, Rauws E AJ, Huibregtse K, Gouma D J. Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones.  Gastrointest Endosc. 1997;  46 514-519
• 21 Deziel D J. Complications of cholecystectomy.  Surg Clin N Am. 1994;  74 809-823
• 22 Sugiyama M, Atomi Y. Longterm effects of endoscopic sphincterotomy on gall bladder motility.  Gut. 1996;  39 856-859
• 23 Sharma B C, Agarwal D K, Baijal S S. et al . Effect of endoscopic sphincterotomy on gall bladder bile lithogenicity and motility.  Gut. 1998;  42 288-292
• 24 Riemann J F, Lux G, Förster P. Long-term results after endoscopic papillotomy.  Endoscopy. 1983;  15 165-168