Risk factors for stone recurrence after laparoscopic common bile duct exploration of CBD stones Chul Woong Kim, Ju Ik Moon, In Seok Choi Department of Surgery, Konyang University Hospital, Daejeon, Korea

Introduction Management of CBD stone ERCP with EST and stone extraction (First line management) Laparoscopic CBD exploration with stone extraction (Alternative therapeutic approach ) Gastrointestinal Endoscopy, Volume 74, No. 4 : 2011 The American Journal of Surgery, Vol 206, No 4, October 2013 Recurrent rate of endoscopic treatment : 5 – 30 % Korean J Gastroenterol 2015;66:251-254

Introduction Risk factor of recurrence CBD stone after ERCP Previous cholecystectomy Mechanical lithotripsy CBD duct dilatation & Stricture of CBD Existed of diverticulum around ampulla of vater CBD angle : under 145˚ Gastrointestinal Endoscopy 2004 ; Volume 59 : AB197 Gastroenterology. 1990 Apr ; 98(4) : 1008-12 Gastrointest Endoscopy 1998 Nov; Volume 48 : 457-64 Gastrointest Endoscopy 2001 ; Volume 54 : 42-48 Gastroenterol Hepatology 2006 May;18(5):461-4

Purpose However, risk factors of stone recurrence after laparoscopic CBD exploration are still not established. To identify risk factors for stone recurrence after laparoscopic CBD exploration

Materials and methods Patients March 2001 ~ December 2015, Retrospective review Konyang University Hospital, Daejeon, Korea Total 279 patients treated with laparoscopic CBD exploration Exclusion Total 24 patients Intrahepatic duct (IHD) stones : 19 patients Combine operation : 3 patients CBD exploration undergone in other hospitals : 2 patients

Laparoscopic CBD exploration Materials and methods Laparoscopic CBD exploration N = 279 Recurrence N = 24 No recurrence N = 231 Exclusion Intrahepatic duct(IHD) stones : 19 patients Combine operation : 3 patients CBD exploration (other hospitals) : 2 patients 9.4 %

Materials and methods Methods Analyzed factors Compared with recurrent 24 patients and no recurrent 231 patients Recurrence of stones : 12 months after op Mean of recurrent months : 43.7 months Follow up : 1 month after op Lab data - LFT, Ultrasonography 12 month after op – CT scan or MRCP Analyzed factors Age, Sex, BMI Operative factors : operation time, blood loss Duration of admission period Stone size , multiple or single stone , duct dilatation Previous endoscopic sphincterotomy (EST)

Results Table 1. Patient characteristic : diagnosed CBD stone Variables All patients (n=255) Age (years) 70.9 ± 13.6 Sex Male 119 (46.7%) Female 136 (53.3%) BMI (Kg/m²) 22.6 ± 3.9 < 25 Kg/m² 196 (76.9%) ≥ 25 Kg/m² 59 (23.1%) Previous surgery Hx. Upper 47 (18.4%) Lower 20 (7.8%) ASA score < 3 170 (66.7%) ≥ 3 85 (33.3%) Operation time (min) 116.4 ± 57.4 Blood loss (ml) 55.4 ± 104.2 T-tube insertion 22 (8.6%) Variables All patients (n=255) Hospital stay (days) 6.6 ± 3.6 Complication 13 (5.1 %) Stone size (mm) 13.1 ± 7.9   < 13 mm 121 (47.5%) ≥ 13 mm 134 (52.5%) Previous CBD stone history yes 16 (6.3%) Previous cholecystectomy 20 (7.8%) Previous EST 55 (21.6%) Duct dilatation 193 (75.7%) Multiple stone 165 (64.7%) Follow up (months) 56.7 ± 44.9

Results Table 2. Univariate analysis for risk factors in recurrent CBD stone Variables No recurrence (n=231) Recurrence (n=24) P value Age (yrs) 70.9 ± 13.9 70.9 ± 10.1 0.994 < 80 163 (70.6%) 19 (79.2%) 0.480 ≥ 80 68 (29.4%) 5 (20.8%) Sex Male 124 (53.7%) 12 (50.0%) 0.831 Female 107 (46.3%) BMI (kg/m2) 22.6 ± 4.0 22.4 ± 2.8 0.699 < 25 Kg/m² 176 (76.2%) 20 (83.3%) 0.612 ≥ 25 Kg/m² 55 (23.8%) 4 (16.7%) Previous surgery Hx. Upper 42 (18.2%) 0.941 Lower 18 (7.8%) 2 (8.3%) ASA score < 3 151 (65.4%) 0.255 ≥ 3 80 (34.6%)

Previous cholecystectomy Results Table 2. Univariate analysis for risk factors in recurrent CBD stone Variables No recurrence (n=231) Recurrence (n=24) P value Operation time (min) 116.3 ± 57.7 117.6 ± 55.9 0.914 Blood loss (ml) 55.6 ± 105..0 52.9 ± 98.8 0.900 Hospital stay (days) 6.4 ± 3.4 8.3 ± 5.0 0.015 Stone size (mm) 13.1 ± 8.1 12.9 ± 5.4 0.896 < 13 mm 107 (46.3%) 14 (58.3%) 0.289 ≥ 13 mm 124 (53.7%) 10 (41.7%)   Previous CBD stone Hx. yes 14 (6.1%) 2 (8.3%) 0.653 Previous cholecystectomy 16 (6.9%) 4 (16.7%) 0.104 Previous EST 45 (19.5%) 0.018 Duct dilatation 172 (74.5%) 21 (87.5%) 0.213 Multiple stone 144 (62.3%) 0.013 Follow up (months) 51.5 ± 41.9 106.1 ± 42.9 < 0.001

Results Table 3. Multivariate analysis for risk factors in recurrent CBD stone Variables Hazard ratio 95% CI P value Multiple stone 3.822 1.088 – 13.432 0.037 Previous EST 2.713 1.013 – 7.265 0.047

Conclusion According to our results, patients who have multiple stones and previous EST were statistically significant higher recurrent rates after laparoscopic CBD exploration of CBD stones So, these patients should be considered careful observation and necessary long term follow up