Why is there recurrence after transcystic laparoscopic bile duct clearance? Risk factor analysis

Aim: Incidence of common bile duct stones (CBDS) is approximately 10% in patients with symptomatic gallstones undergoing laparoscopic cholecystectomy. Transcystic laparoscopic common bile duct exploration (TC-CBDE) is safe and efficient in achieving bile duct clearance from stones, with a success rate of between 85% and 95%. The aim of this retrospective study is the evaluation of risk factors and recurrence in patients treated with TC-CBDS. Methods: From October 2003 until September 2007, 110 consecutive patients with common bile duct stones and gallbladder were included in the study. Average age was 64 years (range 21-82 years). The procedure was completed laparoscopically in 106 patients (96.4%): with TCCBDE in 90 patients (85%), who are the object of this study; and with TC-CBDE + perioperative guide wire papillotomy ("rendezvous") in 16 cases (15%). In the 90 patients treated with TC-CBDE which we examined, the risk factors were: preoperative liver function tests, diameter of the common bile duct (normal 8 mm or less), number of stones (≤3 or more), presence of stones with biliary sludge, and pre- or intraoperative diagnosis. Student's test was used for statistical analysis with a P value of <0.05 defined as statistically significant. Result: The conversion rate to open surgery was 3.6%. There were no mortalities. The average operative time was 115.6 min. The morbility rate was 7.7% with 4.8% local complications and 2.9% general complications. Average follow-up on 90 patients (after TC-CBDE) was 28 months (range 4.2-48 months). We found six recurrences (6.7%). The statistic analysis showed that only number of stones >3 with biliary sludge predicted a recurrence (p<0.05) while the other factors did not show important clinical variables. Conclusion: TC-CBDE is safe and effective in the majority of cases of CBDS. The incidence of recurrence is low but there are some risk factors, such as number of stones >3 with biliary sludge, which do not favor the successful outcome of the procedure. In such cases, it is essential that the TC-CBDE is integrated with other procedures which, although more complex, assure the clearance of the bile duct. © Springer Science+Business Media, LLC 2009.