An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction

Background: Endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. Stone recurrence can, however, occur in up to 25% of cases. Risk factors have been poorly defined, but are believed to be related to bile stasis. This study investigated whether an angulated common bile duct (CBD) that may predispose to bile stasis influences symptomatic stone recurrence after successful endoscopic therapy. Methods: This study included 232 consecutive patients (mean age, 64.1 years; 86 men) who had undergone therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones. Data from the follow-up period (36 +/- 17 months) were obtained from medical records and patient questioning. Common bile duct angulation and diameter were measured from the cholangiogram after stone removal. Results: Symptomatic bile duct stones recurred in 16% of the patients (36/232). Three independent risk factors were identified by multivariate analysis: an angulated CBD (angle, <= 145 degrees; relative risk [RR], 5.2; 95% confidence interval [CI], 2.2-12.5; p = 0.0002), a dilated CBD (diameter, >= 13 mm; RR, 2.6; 95% Cl, 1.2-5.7; p = 0.017), and a previous open cholecystectomy (RR, 2.7; 95% CI, 1.3-5.9; p = 0.0117). Gender, age, urgency of procedure, or a periampullary diverticulum did not influence the recurrence rate. Conclusions: Angulation of the CBD (<= 145 degrees) on endoscopic cholanglography, a dilated CBD, and a previous open cholecystectomy are independent risk factors for symptomatic recurrence of bile duct stones. The findings support the role of bile stasis in stone recurrence. Further studies using these data prospectively to identify high-risk patients are warranted.