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Risk factors and management of primary choledocholithiasis: a systematic

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DOI: 10.1111/ans.16211

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Risk factors and management of primary choledocholithiasis: a

systematic review
Jie Zhang and Xiaofeng Ling
Department of General Surgery, Peking University Third Hospital, Beijing, China

Key words Abstract

cholestasis, management, primary
choledocholithiasis, risk factor.
Correspondence
Professor Xiaofeng Ling, Department of General
Surgery, Peking University Third Hospital,
No. 49, Huayuan North Road, Beijing 100191,
China. Email: xiaofengling@bjmu.edu.cn
J. Zhang MBBS; X. Ling MD, PhD.
Accepted for publication 18 July 2020.
doi: 10.1111/ans.16211
Background: Primary choledocholithiasis (PC) is a common disease in biliary surgery.
The treatment is always challenging due to its high recurrence. A systemic review is under-
taken to determine the risk factors for recurrence and provide with the individualized man-
agement strategy.
Methods: Electronic databases PubMed (Medline), Embase and Cochrane Central Register
of Controlled Studies were searched for relevant articles on risk factors for PC recurrence.
Its therapeutic intervention was also collected and analysed.
Results: A total of 36 articles were eligible for inclusion. The recurrent risk factors include
abnormalities of biliary anatomy (peripapillary diverticulum), dynamics (choledochal dila-
tion, sharp angulation and stone number), metabolism (advanced age and hypothyroidism)
and bacterial infection (Enterobacter and Helicobacter pylori). These factors eventually
induce cholestasis and stone formation. At present, there is no guideline and expertise con-
sensus for PC management. The treatment mainly consists of stone retrieval approaches and
internal drainage surgeries. The former are minimally invasive methods: endoscopic
sphincterotomy (EST), papillary balloon dilation (EPBD) and laparoscopic common bile
duct exploration (LCBDE). The latter include choledochoduodenostomy (CDS) and
choledochojejunostomy (CJS) with Roux-en-Y reconstruction. By far, the internal drainage
surgeries have significantly lower recurrence than stone retrieval approaches.
Conclusion: Abnormal biliary anatomy, dynamics, metabolism and bacterial infection are
the risk factors for PC. Both EST/EPBD and LCBDE can be performed as initial treatment.
For recurrent PC, CDS is more suitable to the elderly, while Roux-en-Y CJS reserves for
young patients or those in good conditions.

Introduction
Primary choledocholithiasis (PC) is a common disease and tends to
recur. The stone is originally formed in choledochus, usually with bili-
ary obstruction and infection. According to Saharia et al.,1 it is first
defined as (i) previous cholecystectomy without bile duct exploration;
(ii) detection of bile duct stones at least 2 years after cholecystectomy;
and (iii) no evidence of biliary stricture prior to surgery. It is different
from the secondary choledocholithiasis caused by the passage of gall-
stone or hepatolithiasis. The primary common bile duct (CBD) stone,
identified as calcium bilirubin (mostly pigment stone) by infrared spec-
troscopy, is brown, soft, earthy and easily crushable.2 To date, the
exact aetiology and overall prevalence remain unclear. It seems more
common in Asia than in western countries.3,4 The treatment is always
challenging due to high recurrence (up to 41.7%).3
Here we elucidate the risk factors for PC and introduce the status
of its management.
Methods
The present review was conducted in accordance with the Pre-
ferred Reporting Items for Systematic Reviews and Meta-Ana-
lyses. PubMed (Medline), Embase and Cochrane Central
Register of Controlled Studies were searched (deadline: 30 April
2020). The terms and relative variants were as follows: ‘pri-
mary’, ‘choledocholithiasis/common bile duct stone/common
bile duct calculi’, ‘recurrent/recurrence’, ‘risk factor/risk fac-
tors’, ‘endoscopic sphincterotomy/EST’, ‘endoscopic papillary
balloon dilation/EPBD’, ‘common bile duct exploration/CBDE’,

© 2020 Royal Australasian College of Surgeons ANZ J Surg (2020)

2 Zhang and Ling
‘choledochoenterostomy/choledochoduodenostomy/
choledochojejunostomy/Roux-en-Y’.
English language articles and selected studies in Chinese were
included. Titles, abstracts and full-text articles were screened
sequentially for inclusion.
Results
No guideline, systematic review or expertise consensus for PC are
identified by far. Articles that failed to clarify the definite PC data
were excluded. Finally, a total of 36 articles satisfied the inclusion
criteria. A flowchart is illustrated in Figure 1. Meta-analysis cannot be
performed because there is little randomized controlled trial or large-
scale clinical trial at present. However, the previous studies in this
field are still beneficial to clinical practice and further investigation.
Risk factors
Abnormal anatomy and dynamics
Peripapillary diverticulum. With the improvement of imaging tech-
nology, peripapillary diverticulum (PAD) has been detected more
often, especially in the elderly.5 It is classified into three types:6
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart of study selection process.
type I, papilla inside the diverticulum; type II, on the rim of diver-
ticulum; and type III, within 2 cm from a diverticulum. It was con-
firmed that patients with PAD are 2.6 times more likely to have PC
than those without.7 A multivariate analysis confirmed the type of
diverticulum (I and II) was an independent risk factor for PC recur-
rence (relative rate (RR) = 7.4, 95% confident interval (CI) 1.06–
51.79, P = 0.044).8 Another study had a similar result in a multivar-
iate analysis (odds ratio (OR) = 73.6, 95% CI 2.1–2575.3,
P = 0.02).9 Possible mechanisms are10 as follows: (i) Large PAD
tended to have distortion of the CBD anatomy.11 It might interfere
with biliary drainage by compressing CBD, leading to cholestasis
and stone formation. (ii) PAD was a hotbed for the proliferation of
β-glucuronidase producing bacteria.2 (iii) Diverticulitis could
decrease muscular tone and the contractile activity of Oddi sphinc-
ter.12 Fluid in PAD could reflux into CBD and trigger brown pig-
ment stone formation.
Abnormal biliary structure. Kim et al.8 demonstrated that after
stone removal, the larger CBD group (in diameter 13 mm or
greater) had more frequent stone recurrences (RR = 10.1, 95% CI
1.05–97.52, P = 0.045). The dilated CBD could not shrink after
stone clearance due to loss of elasticity caused by chronic
© 2020 Royal Australasian College of Surgeons
Primary choledocholithiasis: risk factors and management
Fig. 2. Angulation of primary choledocholithiasis on magnetic resonance
cholangiopancreatography.
inflammation and fibrosis.8 Sustained CBD dilation is a premise of
inadequate bile drainage and a potential risk factor for
lithogenesis.13
Ductal angulation was evaluated in two-dimensional planes on
cholangiogram. Keizman et al.14 illustrated that sharp CBD angula-
tion (<145 ; Fig. 2) was one of the independent factors for stone
recurrence (RR = 5.2, 95% CI 2.2–12.5, P = 0.0002). The degree
might be a useful consideration for CBD stone formation.15 It was
reasonable to speculate that bile stasis becomes worse as the distal
angulation becomes more acute.16 Sharp angulation might predis-
pose to cholestasis and thus promote stone recurrence.17
Stone number. An endoscopic retrograde cholangiopancreatography
database (894 cases) was reviewed by Yoo et al.18 It was demon-
strated that CBD stone number (≥2) was associated with PC recur-
rence by multivariate analysis (OR = 3.232, 95% CI 1.344–7.773,
P = 0.009). With a consistent result, Oak et al.9 verified the pres-
ence of multiple CBD stones as an independent factor for stone
recurrence (OR = 6.7, 95% CI 1.1–28.6, P = 0.04). Patients might
have tiny residual stone fragments more frequently after stone
extraction. The missed sediments unidentified by cholangiography
could delay bile drainage and act as lithogenic core.19
Abnormal metabolism
Advanced age. Keizman et al.20 found that after endoscopic clear-
ance, the elderly (mean age: 84 ± 3.7 years) are prone to develop
recurrent PC than youngers (mean age: 36.2 ± 9.9 years) with a sig-
nificant difference (recurrence rate: 20% versus 4%; P < 0.0001).
The elderly often present with multiple risk factors, including PAD
(P = 0.011), CBD dilation (≥13 mm, P < 0.001) and sharp CBD
angulation (≤145 , P < 0.001).
© 2020 Royal Australasian College of Surgeons
3
Hypothyroidism. Inkinen et al.21 found a significant higher preva-
lence of hypothyroidism in the CBD stone group (7/86, 8.1%) than
in the control group (1/86, 1.2%). Laukkarinen et al.22,23 verified
that thyroxine had a direct pro-relaxing effect on human Oddi
sphincter in both experimental and clinical studies. Thyroxine defi-
ciency might explain the increased CBD stone prevalence in
patients with hypothyroidism. It was confirmed the higher inci-
dence of CBD stones in subclinical and borderline-subclinical
hypothyroidism (10.2%) compared with non-gallstone controls
(2.8%), (P = 0.026).23
Biliary infection (Enterobacter and Helicobacter pylori)
The overall incidence of bacteria in CBD stone reached up to
88.1%, even higher (100%) in pigment stone.24 Among the 42 cul-
ture samples from brown pigment stones, 17 (40.5%) were positive
for Enterococci, followed by Escherichia coli (E. coli, 16.7%).25
These bacteria secret β-glucuronidase which decomposes conju-
gated bilirubin into unconjugated bilirubin, and the latter combines
with calcium ion to form precipitation of calcium bilirubinate.26
Certain subtypes of E. coli produce phospholipases A2 that hydro-
lyzes phospholipid into free fatty acids and lysolecithin, both of
which participate in pigment stone formation.27,28 Meng et al.29
verified Helicobacter pylori infection might involve in pigment
stone formation. They employed polymerase chain reaction to
screen H. pylori-DNA in bile and mucosa of bile duct. The results
showed the positive rates in pigment stone group (40 cases) were
much higher than the control group, respectively (bile: 32.50% ver-
sus 12.50%, mucosa: 57.50% versus 0, P < 0.01).
Management
PC management mainly consists of stone retrieval approaches and
surgical biliary drainages. Stone retrieval approaches become
increasingly popular,3 particularly in the minimally invasive era. In
contrast, surgical biliary drainages were used more often before the
21th century. They are neglected nowadays probably because of
higher requirement of patient’s general condition and digestive tract
reconstruction. Literatures mostly focus more on the technical prob-
lems rather than the disease entity. Clinical researches including
definite PC data with long-term outcomes were collected in the
Tables 1,S1.
Stone retrieval approaches
Endoscopic sphincterotomy. Since 1974, endoscopic sphincterotomy
(EST) has been applied to choledocholithiasis.30 It is believed a safe
and effective procedure for PC.31,32 Once the stones are too hard and
large to be removed, an endoscopic nasobiliary drainage tube or stent
might be an alternative.3,33 Observational studies showed stone recur-
rence was still high (Table 1). The stones recurred mostly within
3 years after EST.34 The rate of multiple recurrences was 1.8%, and
44% of them developed three or more times. The percentage of
cumulative recurrence of PC were 11.8, 16.1 and 22.9 at 5, 10 and
15 years, respectively.35 After EST, Oddi sphincter, functioning as a
one-way valve between biliary system and intestinal tract, is damaged
permanently.36 Thus, CBD pressure greatly decreases, leading to
4 Zhang and Ling

Table 1 Summary of main clinical studies for primary choledocholithiasis

Source Study design Follow-up duration Group (n) Recurrence rate (%) P-value

Kim et al.8
Observational retrospective study Mean: 2.2 ± 1.1 years EST (47) 21.3 /
Doi† et al.42 Retrospective PSM cohort study 46.8–129.2 months EST (36) 19.4 0.453
42–139.3 months EPBD (39) 12.8
Uchiyama† et al.3 Observational retrospective study 5–19 years EST (36) 16.7 <0.05
CBDE (12) 41.7 <0.05*
CDS (42) 0 /
Lygidakis51 Prospective RCT 6–11 years (mean: 8 ± 2 years) CBDE (45) 20.9 <0.001
CJS (45) 0
†50
Li and Chen Observational retrospective study 1–12 years CBDE (11) 36.4 <0.05*
CDS (39) 2.6 /
CJS (34) 14.7 <0.05*
Gouma et al.66 Observational retrospective study 5–11 years (median: 8 years) CJS (43) 0 /

*Compared with CDS.

†
Only data of primary choledocholithiasis extracted.
EPBD, endoscopic papillary balloon dilatation; EST, endoscopic sphincterotomy; CBDE, common bile duct exploration; CDS, choledochoduodenostomy; CJS,
choledochojejunostomy with Roux-en-Y reconstruction; PSM, propensity score matched; RCT, randomized controlled trial.

duodenal content reflux.37,38 Post-EST regurgitation induces retro-
grade bacterial translocation and deteriorates cholangitis.39 A case–
control study by Zhang et al.40 showed that duodenal-biliary reflux
was an independent risk factor for PC recurrence (P < 0.001),
whereas the length of sphincterotomy incision was not related to
recurrence. No significant difference was found between medium and
maximal incision groups in a univariate analysis.8
Kohn et al. pursued a policy of repeated endoscopic stone extrac-
tion procedures for recurrent PC to avoid surgical intervention for
nine cases.41 The mean number of procedures was 7.3 (313)
times per patient. Their results implied that endoscopic treatment
brought about a high recurrence and could not eradicate the disease,
although it was safe and could temporarily relieve the biliary
symptoms.
Endoscopic papillary balloon dilation. Endoscopic papillary bal-
loon dilation (EPBD) is utilized to preserve the papillary function
without haemorrhage. It is suitable for those who take in anticoagu-
lant. Doi et al.42 carried out a propensity-matched cohort (246 pairs)
analysis to compare long-term outcomes of EPBD with EST. The
recurrent PC (5/39, 12.8%) of EPBD group was less frequent than
EST group (7/36, 19.4%) without a significant difference (hazard
ratio: 0.644, P = 0.453). Similarly, the cumulative stone recurrence
rate of the EPBD group was lower (P = 0.448). Ohashi et al.43
expressed a concern that small fragments missed by balloon cholan-
giography might act as nidi for stone recurrence.
Laparoscopic CBD exploration. Laparoscopic CBD exploration
(LCBDE) was first introduced in 1991.44 It was an alternative for
multiple, large or occluding stones.45 However, iatrogenic bile duct
injuries could occur on the following conditions: (i) T-tube associ-
ated adhesion and CBD angulation (elbow sign);14,46 (ii) residual
suture, serving as the core of stone formation;47 (iii) lithotripsy-
related injury.48,49 Long-term outcomes of LCBDE showed a high
stone recurrence (36.441.7%)3,50 because it does not alter the bili-
ary structure and lithogenic environment.51
Endoscopic and surgical stone extraction methods are rec-
ommended as equally valid options in terms of efficacy, morbidity
or mortality.52 However, EST clearance could leave a higher inci-
dence (16%) of retained stones compared with open surgery
(6%).53 Nowadays, EST or EPBD is recommended as the first-line
treatment for initial PC. Additionally, endoscopic therapy seems the
prior option in acute cholangitis with debilitating diseases. Never-
theless, LCBDE ought to be performed for large stones,54 keeping
Oddi sphincter intact.
Surgical biliary drainage
Choledochoenterostomy was adopted to treat recurrent PC.55,56
There are two types: choledochoduodenostomy (CDS) and
choledochojejunostomy (CJS) with Roux-en-Y reconstruction.3
Choledochoduodenostomy. CDS was first employed by Sprengel to
deal with choledocholithiasis in 1891.57 It was ever a definitive pro-
cedure for PC in the 1970s.58 Parrilla et al. advocated it for greater
CBD stone (more than 12 mm in diameter).59 ‘Side-to-side’ anasto-
mosis60 was easy and suitable to high-risk patients.3,61 But this type
of anastomosis is susceptible to retrograde cholangitis (6%)62,63 or
‘Sump syndrome’.64 And anastomosis width was suggested wide
enough55,62 to keep from the stenosis. ‘End-to-side’ may be a better
method to reduce regurgitation and biliary infection. Senthilnathan
et al.65 advocated laparoscopic CDS as a reliable rescue procedure
for complicated CBD stones.
A retrospective study on the long-term prognosis of PC was car-
ried out by Uchiyama et al.3 There were three groups: CBD explo-
ration (CBDE, n = 12), CDS (n = 42) and EST (n = 36). The
follow-up rate was 100% with the mean of 9.6 years. The recur-
rence rate of CDS group (0%) was much lower than both of the
CBDE (41.7%, P < 0.05) and EST groups (16.7%, P < 0.05). The
late CDS complications included severe gastritis (n = 2), gastric
ulcer (n = 3), gastric cancer (n = 4) and oesophageal cancer
(n = 1).3 Li and Chen50 had a similar result.
A prospective, randomized study51 was carried out to compare
the outcomes of CDS with CBDE. Each group enrolled 45 patients.
The CDS group had much lower recurrence (0% versus 20.9%)
with a significant difference (P < 0.05). CDS was thought a

© 2020 Royal Australasian College of Surgeons

Primary choledocholithiasis: risk factors and management
Fig. 3. Management strategy for primary chole-
docholithiasis (PC). CDS, choledochoduode-
nostomy; CJS, choledochojejunostomy with
Roux-en-Y reconstruction; EPBD, endoscopic
papillary balloon dilatation; EST, endoscopic
sphincterotomy; LCBDE, laparoscopic common
bile duct exploration.
preferable approach for old patients to prevent recurrence owing to
its simplicity and effectiveness.50
Choledochojejunostomy. Before the availability of EST, CJS was
performed for choledocholithiasis.66 More than a decade ago, CJS
was not commonly selected as a treatment option for chole-
docholithiasis because: (i) endoscopic cannot be performed when
anastomotic stenosis has occurred and (2) surgical techniques are
complicated.3 However, these technical problems have been
resolved nowadays.67,68 Theoretically, CJS is a good approach for
PC,59 especially with PAD.69 Gouma et al.66 completed a retro-
spective study aiming to observe the long-term outcomes after CJS.
The median follow-up period was 8 years. Their results were satis-
factory: no cholangitis symptoms or signs recurred. Lee et al.70
believed that experienced surgeons could perform laparoscopic CJS
with acceptable results through careful video review, education of
the surgical team and various technical tips.
Discussion
To our knowledge, this is the first systematic review to evaluate the
risk factors and management of PC. Based on our review, anoma-
lous biliary anatomy, dynamics and metabolism are the fundamen-
tal risk factors for recurrent PC. All of them can induce inadequate
bile drainage and cholestasis, which is the prerequisite of pigment
stone formation. Under these circumstances, β-glucuronidase pro-
ducing bacteria colonize in CBD and facilitate precipitation of cal-
cium bilirubinate. In order to improve the long-term outcomes, it is
important for doctors to identify the patients at high risk for recur-
rence. Then the appropriate intervention could be conducted to
eliminate the recurrent pathophysiology.71
Lygidakis51 believed the better biliary drainage, the less stone
recurrence. Therefore, the management strategy should focus on
reducing cholestasis. EST or EPBD and LCBDE are the main-
stream in the treatment of choledocholithiasis at present.26 In the
era of minimally invasive surgery, minimized injury deeply roots in
both minds of patients and doctors. LCBDE brings about small
wounds, fast recovery and short hospitalization. But it cannot cor-
rect the abnormal biliary structure nor relieve cholestasis. It has the
highest recurrence among the treatment modalities. With regard to
EST and EPBD, although they can partially improve bile drainage
through sphincterotomy, their effectiveness is still limited
(Table 1). Enlarged incision through sphincterotomy cannot reduce
© 2020 Royal Australasian College of Surgeons
5
the stone recurrence during long-term follow-up visit.8 Instead, it
may cause papillary scar contracture and stenosis. In clinical prac-
tice, quite a few surgeons or endoscopists choose treatment based
on their own experiences or skills rather than the disease’s
pathogenesis,3 so the stone recurrence remains high.50 Kohn
et al.41 believed the endoscopic management did not prevent recur-
rence of choledocholithiasis. On the contrary, repeated EST or
EPBD procedures mean high cost of multiple consumable items,
regular hospital attendance and excessive radiation exposures.
Hence, EST could be employed for initial treatment, particularly
for acute cholangitis, and the elderly unfit for or refusal to sur-
gery.66 LCBDE is an alternative choice for larger stones. For recur-
rent PC, adequate bile drainage is a desire.72,73
Choledochoenterostomy could establish a large anastomotic site to
relieve bile stasis. Both CDS and CJS had satisfactory long-term
outcomes. As mentioned above, ‘end-to-side’ CDS is fit for the
elderly with safety, simplicity and effectiveness. CJS is reserved for
the youngsters or patients in good conditions because CDS can
result in gastric diseases.66 The management strategy is summa-
rized in Figure 3.
Limitation
The enrolled studies are mostly retrospective. Randomized con-
trolled trial is rare. A proportion of the clinical investigations were
conducted two decades ago and the evidence quality was not high
enough.
In conclusion, the risk factors for PC include abnormal biliary
anatomy, dynamics and metabolism together with biliary infection.
Cholestasis is the key in the process of CBD stone formation. Only
the establishment of a free flow of bile can eliminate cholestasis
and prevent recurrent choledocholithiasis. EST or EPBD is the first
option for initial treatment. LCBDE is an alternative. CDS is more
suitable to recurrent cases, especially for the elderly. Whereas,
Roux-en-Y CJS reserves for younger patients in good conditions.
More prospective, randomized, multicentric and large-scale clinical
trials are needed.
Acknowledgement
This work was supported by the Beijing Natural Science Founda-
tion (Grant: 7172233).
6 Zhang and Ling
Conflicts of interest
None declared.
References
1. Saharia PC, Zuidema GD, Cameron JL. Primary common duct stones.
Ann. Surg. 1977; 185: 598–604.
2. Sandstad O, Osnes T, Skar V, Urdal P, Osnes M. Common bile duct
stones are mainly brown and associated with duodenal diverticula. Gut
1994; 35: 1464–7.
3. Uchiyama K, Onishi H, Tani M et al. Long-term prognosis after treat-
ment of patients with choledocholithiasis. Ann. Surg. 2003; 238:
97–102.
4. Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A pro-
spective study of common bile duct calculi in patients undergoing lapa-
roscopic cholecystectomy: natural history of choledocholithiasis
revisited. Ann. Surg. 2004; 239: 28–33.
5. Lai KH, Peng NJ, Lo GH et al. Prediction of recurrent chole-
docholithiasis by quantitative cholescintigraphy in patients after endo-
scopic sphincterotomy. Gut 1997; 41: 399–403.
6. Kim CW, Chang JH, Kim JH, Kim TH, Lee IS, Han SW. Size and type
of periampullary duodenal diverticula are associated with bile duct
diameter and recurrence of bile duct stones. J. Gastroenterol. Hepatol.
2013; 28: 893–8.
7. Li X, Zhu K, Zhang L et al. Periampullary diverticulum may be an
important factor for the occurrence and recurrence of bile duct stones.
World J. Surg. 2012; 36: 2666–9.
8. Kim DI, Kim MH, Lee SK et al. Risk factors for recurrence of primary
bile duct stones after endoscopic biliary sphincterotomy. Gastrointest.
Endosc. 2001; 54: 42–8.
9. Oak JH, Paik CN, Chung WC, Lee KM, Yang JM. Risk factors for
recurrence of symptomatic common bile duct stones after cholecystec-
tomy. Gastroenterol. Res. Pract. 2012; 2012: 1–6.
10. Wijarnpreecha K, Panjawatanan P, Manatsathit W et al. Association
between juxtapapillary duodenal diverticula and risk of chole-
docholithiasis: a systematic review and meta-analysis. J. Gastrointest.
Surg. 2018; 22: 2167–76.
11. Christoforidis E, Goulimaris I, Kanellos I, Tsalis K, Dadoukis I. The
role of juxtapapillary duodenal diverticula in biliary stone disease. Gas-
trointest. Endosc. 2002; 55: 543–7.
12. Løtveit T, Osnes M, Aune S, Larsen S. Studies of the choledocho-
duodenal sphincter in patients with and without juxta-papillary duode-
nal diverticula. Scand. J. Gastroenterol. 1980; 15: 875–80.
13. Pereira-Lima JC, Jakobs R, Winter UH et al. Long-term results (7 to
10 years) of endoscopic papillotomy for choledocholithiasis. Multivari-
ate analysis of prognostic factors for the recurrence of biliary symp-
toms. Gastrointest. Endosc. 1998; 48: 457–64.
14. Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct
predisposes to recurrent symptomatic bile duct stones after endoscopic
stone extraction. Surg. Endosc. 2006; 20: 1594–9.
15. Seo DB, Bang BW, Jeong S et al. Does the bile duct angulation affect
recurrence of choledocholithiasis? World J. Gastroenterol. 2011; 17:
4118–23.
16. Kim JH, Kim YS, Kim DK et al. Short-term clinical outcomes based on
risk factors of recurrence after removing common bile duct stones with
endoscopic papillary large balloon dilatation. Clin. Endosc. 2011;
44: 123–8.
17. Costamagna G, Tringali A, Shah SK, Mutignani M, Zuccalà G, Perri V.
Long-term follow-up of patients after endoscopic sphincterotomy for
choledocholithiasis, and risk factors for recurrence. Endoscopy 2002;
34: 273–9.
18. Yoo ES, Yoo BM, Kim JH et al. Evaluation of risk factors for recurrent
primary common bile duct stone in patients with cholecystectomy.
Scand. J. Gastroenterol. 2018; 53: 466–70.
19. Lim JH. Oriental cholangiohepatitis: pathologic, clinical, and radiologic
features. AJR Am. J. Roentgenol. 1991; 157: 1–8.
20. Keizman D, Ish Shalom M, Konikoff FM. Recurrent symptomatic com-
mon bile duct stones after endoscopic stone extraction in elderly
patients. Gastrointest. Endosc. 2006; 64: 60–5.
21. Inkinen J, Sand J, Nordback I. Association between common bile duct
stones and treated hypothyroidism. Hepatogastroenterology 2000; 47:
919–21.
22. Laukkarinen J, Sand J, Aittomaki S et al. Mechanism of the prorelaxing
effect of thyroxine on the sphincter of Oddi. Scand. J. Gastroenterol.
2002; 37: 667–73.
23. Laukkarinen J, Kiudelis G, Lempinen M et al. Increased prevalence of
subclinical hypothyroidism in common bile duct stone patients. J. Clin.
Endocrinol. Metab. 2007; 92: 4260–4.
24. Tabata M, Nakayama F. Bacteria and gallstones. Etiological signifi-
cance. Dig. Dis. Sci. 1981; 26: 218–24.
25. Leung JW, Sung JY, Costerton JW. Bacteriological and electron
microscopy examination of brown pigment stones. J. Clin. Microbiol.
1989; 27: 915–21.
26. Cai JS, Qiang S, Bao-Bing Y. Advances of recurrent risk factors and
management of choledocholithiasis. Scand. J. Gastroenterol. 2017;
52: 34–43.
27. Stewart L, Oesterle AL, Erdan I, Griffiss JM, Way LW. Pathogenesis of
pigment gallstones in Western societies: the central role of bacteria.
J. Gastrointest. Surg. 2002; 6: 891–903.
28. Stewart L, Grifiss JM, Jarvis GA, Way LW. Biliary bacterial factors
determine the path of gallstone formation. Am. J. Surg. 2006; 192:
598–603.
29. Meng XL, Wang ZG, Han WX et al. Relationship between
Helicobacter pylori infection and cholangitis and calculi recurrence
after intrahepatic and extrahepatic bile duct stones. J. Hepatobiliary
Surg. 2009; 17: 50–3.
30. Kawai K, Akasaka Y, Murakami K, Tada M, Koli Y. Endoscopic
sphincterotomy of the ampulla of Vater. Gastrointest. Endosc. 1974;
20: 148–51.
31. Roberts-Thomson IC. Endoscopic sphincterotomy in high-risk patients
with biliary tract disease. Aust. N. Z. J. Surg. 1981; 51: 289–91.
32. Simon DM, Brooks WS Jr, Hersh T. Endoscopic sphincterotomy: a
reappraisal. Am. J. Gastroenterol. 1989; 84: 213–9.
33. Slattery E, Kale V, Anwar W, Courtney G, Aftab AR. Role of long-
term biliary stenting in choledocholithiasis. Dig. Endosc. 2013;
25: 440–3.
34. Tanaka M, Takahata S, Konomi H et al. Long-term consequence of
endoscopic sphincterotomy for bile duct stones. Gastrointest. Endosc.
1998; 48: 465–9.
35. Ando T, Tsuyuguchi T, Okugawa T et al. Risk factors for recurrent bile
duct stones after endoscopic papillotomy. Gut 2003; 52: 116–21.
36. Mu H, Gao J, Kong Q et al. Prognostic factors and postoperative recur-
rence of calculus following small-incision sphincterotomy with papil-
lary balloon dilation for the treatment of intractable choledocholithiasis:
a 72-month follow-up study. Dig. Dis. Sci. 2015; 60: 2144–9.
37. Toouli J. Sphincter of Oddi: function, dysfunction, and its management.
J. Gastroenterol. Hepatol. 2009; 24 (Suppl. 3): S57–62.
38. Ishiguro J. Biliary bacteria as an indicator of the risk of recurrence of
choledocholithiasis after endoscopic sphincterotomy. Diagn. Ther.
Endosc. 1998; 5: 9–17.
© 2020 Royal Australasian College of Surgeons
Primary choledocholithiasis: risk factors and management
39. Disario JA, Freeman ML, Bjorkman DJ et al. Endoscopic balloon dila-
tion compared with sphincterotomy for extraction of bile duct stones.
Gastroenterology 2004; 127: 1291–9.
40. Zhang R, Luo H, Pan Y et al. Rate of duodenal-biliary reflux increases
in patients with recurrent common bile duct stones: evidence from bar-
ium meal examination. Gastrointest. Endosc. 2015; 82: 660–5.
41. Kohn GP, Hassen AS, Banting SW, Mackay S, Cade RJ. Endoscopic
management of recurrent primary bile duct stones. ANZ J. Surg. 2008;
78: 579–82.
42. Doi S, Yasuda I, Mukai T et al. Comparison of long-term outcomes
after endoscopic sphincterotomy versus endoscopic papillary balloon
dilation: a propensity score-based cohort analysis. J. Gastroenterol.
2013; 48: 1090–6.
43. Ohashi A, Tamada K, Tomiyama T et al. Influence of bile duct diame-
ter on the therapeutic quality of endoscopic balloon sphincteroplasty.
Endoscopy 1999; 31: 137–41.
44. Petelin JB. Laparoscopic approach to common duct pathology. Surg.
Laparosc. Endosc. 1991; 1: 33–41.
45. Cuschieri A, Croce E, Faggioni A et al. EAES ductal stone study. Prelim-
inary findings of multi-center prospective randomized trial comparing
two-stage vs single-stage management. Surg. Endosc. 1996; 10: 1130–5.
46. Lee SH, Burhenne HJ. Extrahepatic bile duct angulation by T-tube: the
elbow sign. Gastrointest. Radiol. 1991; 16: 157–8.
47. Atiq O, Patel N, Sreenarasimhaiah J, Agrawal D. Suture material in the
common bile duct causing recurrent stones. Gastrointest. Endosc. 2015;
82: 574–5.
48. Verdonk RC, de Ruiter AJ, Weersma RK. [Treatment of complex bili-
ary stones by cholangioscopy laser lithotripsy in 10 patients]. Ned.
Tijdschr. Geneeskd. 2010; 154: A2085.
49. Yasuda I. Management of the bile duct stone: current situation in Japan.
Dig. Endosc. 2010; 22 (Suppl. 1): S76–8.
50. Li ZF, Chen XP. Recurrent lithiasis after surgical treatment of elderly
patients with choledocholithiasis. Hepatobiliary Pancreat. Dis. Int.
2007; 6: 67–71.
51. Lygidakis NJ. Surgical approaches to recurrent choledocholithiasis.
Choledochoduodenostomy versus T-tube drainage after choledochotomy.
Am. J. Surg. 1983; 145: 636–9.
52. Williams EJ, Green J, Beckingham I et al. Guidelines on the manage-
ment of common bile duct stones (CBDS). Gut 2008; 57: 1004–21.
53. Dasari BV, Tan CJ, Gurusamy KS et al. Surgical versus endoscopic treat-
ment of bile duct stones. Cochrane Database Syst. Rev. 2013: CD003327.
54. Kristiansen VB, Schulze S. [Treatment of common bile duct
stones]. Ugeskr. Laeger 2000; 162: 4245–9.
55. Matsushima K, Soybel DI. Operative management of recurrent chole-
docholithiasis. J. Gastrointest. Surg. 2012; 16: 2312–7.
56. Deutsch AA, Nudelman I, Gutman H, Reiss R.
Choledochoduodenostomy an important surgical tool in the manage-
ment of common bile duct stones. A review of 126 cases. Eur. J. Surg.
1991; 157: 531–3.
57. Cubillos L, Fiallo R, Rodriguez J. Is choledochoduodenostomy in the
treatment of stones in the common bile duct an obsolete technique?
World J. Surg. 1985; 9: 484–92.
© 2020 Royal Australasian College of Surgeons
View publication stats
7
58. Madden JL. Primary common bile duct stones. World J. Surg. 1978; 2:
465–71.
59. Parrilla P, Ramirez P, Sanchez Bueno F et al. Long-term results of
choledochoduodenostomy in the treatment of choledocholithiasis:
assessment of 225 cases. Br. J. Surg. 1991; 78: 470–2.
60. Gurbuz AT, Watson D, Fenoglio ME. Laparoscopic
choledochoduodenostomy. Am. Surg. 1999; 65: 212–4.
61. Aramaki M, Ikeda M, Kawanaka H, Nishijima N, Tsutsumi N, Kano T.
Choledochoduodenostomy: simple side-to-side anastomosis.
J. Hepatobiliary Pancreat. Surg. 2000; 7: 486–8.
62. de Aretxabala X, Bahamondes JC. Choledochoduodenostomy for com-
mon bile duct stones. World J. Surg. 1998; 22: 1171–4.
63. Engin A, Haberal M, Sanac Y. Side-to-side choledochoduodenostomy in
the management of choledocholithiasis. Br. J. Surg. 1978; 65: 99–100.
64. Khan TF, Sherazi ZA, Muniandy S, Mumtaz M. Recurrent pyogenic
cholangitis: ‘sump syndrome’ following choledochoduodenostomy.
Trop. Doct. 1997; 27: 51–2.
65. Senthilnathan P, Sharma D, Sabnis SC et al. Laparoscopic
choledochoduodenostomy as a reliable rescue procedure for compli-
cated bile duct stones. Surg. Endosc. 2018; 32: 1828–33.
66. Gouma DJ, Konsten J, Soeters PB, Von Meyenfeldt M, Obertop H.
Long-term follow-up after choledochojejunostomy for bile duct stones
with complex clearance of the bile duct. Br. J. Surg. 1989; 76: 451–3.
67. Han HS, Yi NJ. Laparoscopic Roux-en-Y choledochojejunostomy for
benign biliary disease. Surg. Laparosc. Endosc. Percutan. Tech. 2004;
14: 80–4.
68. Tsou YK, Lee MS, Chen KF, Lin CH, Sung KF, Wu CC. Double-
balloon enteroscopy-assisted endoscopic retrograde cholangiography
for Roux-en-Y reconstruction patients with papilla of Vater or
bilioenteric anastomosis. Scand. J. Gastroenterol. 2016; 51: 95–102.
69. Miyazawa Y, Okinaga K, Nishida K, Okano T. Recurrent common bile
duct stones associated with periampullary duodenal diverticula and cal-
cium bilirubinate stones. Int. Surg. 1995; 80: 120–4.
70. Lee JS, Hong TH. Laparoscopic choledochojejunostomy in various
hepatobiliary and pancreatic surgeries: A single surgeon’s experience.
Journal of Laparoendoscopic & Advanced Surgical Techniques. 2015;
25: 305–310.
71. Lai KH, Lo GH, Lin CK et al. Do patients with recurrent chole-
docholithiasis after endoscopic sphincterotomy benefit from regular
follow-up? Gastrointest. Endosc. 2002; 55: 523–6.
72. Cetta F. Do surgical and endoscopic sphincterotomy prevent or facili-
tate recurrent common duct stone formation? Arch. Surg. 1993; 128:
329–36.
73. Allen B, Shapiro H, Way LW. Management of recurrent and residual
common duct stones. Am. J. Surg. 1981; 142: 41–7.
Supporting information
Additional Supporting Information may be found in the online ver-
sion of this article at the publisher’s web-site:
Table S1. Additional clinical studies for primary choledocholithiasis