2024
Fábio Pereira Correia, Henrique Coelho, Mónica Francisco, Gonçalo Alexandrino, Joana Carvalho e Branco, Jorge Canena, Luís Carvalho Lourenço, David Horta
Endoscopie – 28/04/2024 – Communication orale
Aims: ERCP is associated with a non-negligible rate of adverse events (up to 10%) and should be reserved for procedures with therapeutic intent. Choledocholithiasis is the most common indication, however, if there is spontaneous migration of stones, ERCP becomes unnecessary. The incidence of this occurrence and the predictive factors are subject to discussion. The aim of this study was to evaluate predictive factors for spontaneous migration of CBD stones, in patients diagnosed with CBD stones on imaging and native papilla, which correlate with unnecessary ERCP.
Methods: Retrospective study including patients with native papilla who underwent ERCP after imaging diagnosis of choledocholithiasis, between January 2020 and June 2023, in a center with a high volume of ERCP (>400/year). The following data were recorded: patient characteristics, laboratory evaluation, imaging tests, time between the diagnosis of choledocholithiasis and ERCP, data relating to ERCP and complications. Patients were divided into 2 groups (presence or absence of CBD stones on ERCP), and univariable and logistic regression analyses were performed to determine independent factors of unnecessary ERCP.
Results: 334 patients were included (mean age 71.7 years; 60.8% female): 256 (76.6%) with CBD stones in ERCP and 78 (23.4%) without. The presentation with pancreatitis (OR 2.302, p=0.02) and acute cholangitis (OR 0.167; p<0.001) were different between the groups, but only pancreatitis proved to be an independent factor for spontaneous biliary clearance. Regarding laboratory tests, only the bilirubin value immediately prior to ERCP revealed significant differences between the groups (2.81 vs. 0.83 mg/dL; p<0.001), with bilirubin < 2 mg/dl being a predictor of unnecessary ERCP (OR 8.554; p<0.001). About imaging findings, the presence of stones with dimensions ≤ 5 mm (OR 18.2; p<0.001) and a CBD diameter < 10 mm (OR 2.650; p < 0.001) proved to be predictive factors for ERCP without CBD stones. Of the patients undergoing ERCP within 7 days of diagnosis, 16.3% did not have choledocholithiasis, compared to 37% when ERCP was performed after 7 days (p<0.001). This cut-off (ERCP > 7 days after diagnosis) confirmed to be a predictor of unnecessary ERCP (OR 2.743, p<0.001). There were 5 pancreatitis (4 mild and one severe) in the group of patients without evidence of choledocholithiasis on ERCP. Conclusions: In patients with predictive factors for spontaneous clearance of CBD stones, such as biliary pancreatitis, bilirubin prior to ERCP < 2 mg/dL, stones ≤ 5 mm, CBD < 10 mm, and diagnosis > 7 days, especially if combined, an additional test with high sensitivity (such as endoscopic ultrasound) should be considered to minimize unnecessary ERCPs and possible complications