European Journal of Cardiovascular Medicine

Gallstone disease is a prevalent gastrointestinal condition worldwide, with cholelithiasis affecting approximately 10–15% of the adult population (1). Among these patients, 10–20% develop common bile duct (CBD) stones, necessitating prompt intervention to prevent complications such as cholangitis, pancreatitis, or obstructive jaundice (2). Endoscopic retrograde cholangiopancreatography (ERCP) has become the standard therapeutic approach for CBD stone removal prior to cholecystectomy (3). It offers a minimally invasive method for stone extraction and biliary decompression, often serving as a bridge to elective laparoscopic cholecystectomy (4).

Despite the high success rate of ERCP, residual or missed CBD stones continue to pose a significant clinical challenge, with reported incidences ranging from 4% to 15% even after seemingly successful procedures (5,6). These retained stones may result from factors such as incomplete ductal clearance, small or impacted calculi, and technical limitations of the procedure (7). Residual stones can lead to postoperative complications including bile leakage, recurrent biliary obstruction, and pancreatitis, potentially increasing morbidity, hospital stay, and need for reintervention (8,9).

The accurate detection and removal of CBD stones during ERCP are therefore critical to ensuring optimal surgical outcomes. However, in many cases, residual stones are only discovered intraoperatively or postoperatively, underscoring the need for further evaluation of their clinical impact (10). This study aims to assess the postoperative complication rates associated with residual CBD stones in patients undergoing cholecystectomy after ERCP and to highlight the importance of meticulous bile duct clearance in minimizing adverse outcomes.

A total of 180 patients were enrolled and divided into two groups. Group A comprised patients (n=90) with complete clearance of common bile duct (CBD) stones post-ERCP, as confirmed by cholangiography or follow-up imaging. Group B included patients (n=90) who had residual CBD stones detected either intraoperatively during cholecystectomy (by intraoperative cholangiogram or direct CBD exploration) or during the postoperative period (based on clinical symptoms and imaging findings).

Data collected from patient records included demographic details (age, gender), clinical presentation, laboratory findings, ERCP procedure notes, intraoperative findings, postoperative complications, and duration of hospital stay. Postoperative complications analyzed were bile leakage, pancreatitis, wound infection, and re-admission due to biliary events within 30 days of surgery.

The primary outcome measured was the incidence of postoperative complications in relation to the presence of residual CBD stones. Secondary outcomes included length of hospital stay and need for additional procedures. Statistical analysis was performed using SPSS version 26. Continuous variables were expressed as mean ± standard deviation (SD) and compared using the independent t-test. Categorical variables were presented as frequencies and percentages and analyzed using the Chi-square test or Fisher’s exact test where appropriate. A p-value less than 0.05 was considered statistically significant.

A total of 180 patients were included in the study, with 90 patients in each group. The mean age of the participants was 52.6 ± 13.4 years in Group A and 54.1 ± 12.8 years in Group B. There was no statistically significant difference in age or gender distribution between the groups (p>0.05).

Postoperative complications were more frequently observed in Group B (patients with residual CBD stones) compared to Group A (patients with complete CBD clearance post-ERCP). Biliary leakage was reported in 13 patients (14.4%) in Group B, compared to 3 patients (3.3%) in Group A (p=0.01). Similarly, postoperative pancreatitis was observed in 10 patients (11.1%) in Group B and in 2 patients (2.2%) in Group A (p=0.02). Wound infections occurred in 8 patients (8.9%) in Group B and in 4 patients (4.4%) in Group A, though the difference was not statistically significant (p=0.21).

Additionally, the average hospital stay was significantly longer in Group B (6.8 ± 2.0 days) compared to Group A (4.5 ± 1.5 days) (p<0.001) (Table 1). Re-intervention due to persistent or recurrent biliary symptoms was required in 7 patients (7.8%) in Group B, while only 1 patient (1.1%) in Group A required further intervention (p=0.03) (Table 2).

Table 1: Postoperative Complications Between Group A and Group B

Table 2: Reintervention and Readmission Rates

These results indicate a statistically significant association between residual CBD stones and increased postoperative morbidity, particularly biliary leakage, pancreatitis, and extended hospitalization duration (Table 1 and Table 2).

The findings of this study highlight the significant impact of residual common bile duct (CBD) stones on postoperative outcomes in patients undergoing cholecystectomy following ERCP. Patients with residual CBD stones demonstrated a notably higher incidence of postoperative complications, including biliary leakage, pancreatitis, prolonged hospitalization, and need for reintervention, when compared to those with complete CBD clearance. These results align with previous literature emphasizing the clinical burden of retained CBD stones after ERCP (1,2).

Although ERCP is widely accepted as the gold standard for the diagnosis and removal of CBD stones, its effectiveness is not absolute. Incomplete ductal clearance can occur due to small or impacted stones, anatomical variations, or limitations in endoscopic visualization (3,4). Studies have reported residual stone rates ranging from 4% to 15%, which corresponds with the complication rates observed in our study (5,6). These retained stones may later migrate or obstruct the biliary tract, leading to secondary complications such as biliary leakage or pancreatitis (7,8).

The increased rate of biliary leakage observed in Group B patients can be attributed to ductal trauma or persistent distal obstruction caused by retained calculi, which interferes with normal bile flow and pressure regulation (9). Similarly, the higher incidence of pancreatitis in this group is consistent with the pathophysiology of pancreatic duct irritation due to obstruction at the ampulla of Vater, a known consequence of unresolved CBD stones (10). These findings support the need for meticulous stone clearance during ERCP, especially in patients with complex biliary anatomy or multiple calculi (11).

Extended hospital stay and the need for reintervention further underline the economic and clinical consequences of residual stones. Inadequate initial management can result in delayed recovery, increased healthcare costs, and added psychological distress for the patient (12,13). Intraoperative cholangiography or postoperative magnetic resonance cholangiopancreatography (MRCP) can play an essential role in identifying missed stones and should be considered in high-risk patients or those with suspicious symptoms (14,15).

This study's retrospective nature is a limitation, as it may be subject to information bias due to reliance on existing medical records. Moreover, the lack of standardized imaging follow-up in all patients may have led to underestimation of asymptomatic retained stones. However, the strength of this study lies in its practical implications, emphasizing the necessity of vigilant assessment during ERCP and advocating for improved strategies to confirm ductal clearance.

In conclusion, the presence of residual CBD stones significantly increases the risk of adverse postoperative outcomes in patients undergoing post-ERCP cholecystectomy. Enhanced techniques for stone detection and removal, along with appropriate postoperative surveillance, are essential to reduce morbidity and improve patient outcomes.

1. Bergeron E, Doyon T, Manière T, Désilets É. Cholecystectomy following endoscopic clearance of common bile duct during the same admission. Can J Surg. 2023;66(5):E477-E484.
2. Bergeron E, Doyon T, Manière T, Désilets É. Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event. Surg Endosc. 2023;37(12):9546-9555.
3. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(12):CD003327.
4. Dasari BV, Tan CJ, Gurusamy KS, Martin DJ, Kirk G, McKie L, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev. 2013;(9):CD003327.
5. Lujian P, Xianneng C, Lei Z. Risk factors of stone recurrence after endoscopic retrograde cholangiopancreatography for common bile duct stones. Medicine (Baltimore). 2020;99(27):e20412.
6. Di Mauro D, Ricciardi E, Siragusa L, Manzelli A. Outcome of laparoscopic common bile duct exploration after failed endoscopic retrograde cholangiopancreatography: a comparative study. J Laparoendosc Adv Surg Tech A. 2019;29(11):1391-1396.
7. De Silva HM, Howard T, Yong T, Hodgson R. Comparing stone recurrence following surgical common bile duct exploration or endoscopic stone extraction for patients with common bile duct stones. J Laparoendosc Adv Surg Tech A. 2023;33(4):389-396.
8. Syrén EL, Enochsson L, Eriksson S, Eklund A, Isaksson B, Sandblom G. Cardiovascular complications after common bile duct stone extractions. Surg Endosc. 2021;35(7):3296-3302.
9. Lyu Y, Cheng Y, Li T, Cheng B, Jin X. Laparoscopic common bile duct exploration plus cholecystectomy versus endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for cholecystocholedocholithiasis: a meta-analysis. Surg Endosc. 2019;33(10):3275-3286.
10. Yoo ES, Yoo BM, Kim JH, Hwang JC, Yang MJ, Lee KM, et al. Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy. Scand J Gastroenterol. 2018;53(4):466-470.
11. Zhou XD, Chen QF, Zhang YY, Yu MJ, Zhong C, Liu ZJ, et al. Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones. World J Gastroenterol. 2019;25(4):485-497.
12. Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gall bladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg. 2009;7(4):338-346.
13. Adamek HE, Kudis V, Jakobs R, Buttmann A, Adamek MU, Riemann JF. Impact of gallbladder status on the outcome in patients with retained bile duct stones treated with extracorporeal shockwave lithotripsy. Endoscopy. 2002;34(8):624-627.
14. Pencev D, Brady PG, Pinkas H, Boulay J. The role of ERCP in patients after laparoscopic cholecystectomy. Am J Gastroenterol. 1994;89(9):1523-1527.
15. de Sousa S, Tobler O, Iranmanesh P, Frossard JL, Morel P, Toso C. Management of suspected common bile duct stones on cholangiogram during same-stay cholecystectomy for acute gallstone-related disease. BMC Surg. 2017;17(1):39.