1. 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

2. 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:

3. 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 Apr ; 98(4) :
Gastrointest Endoscopy 1998 Nov; Volume 48 :
Gastrointest Endoscopy 2001 ; Volume 54 : 42-48
Gastroenterol Hepatology 2006 May;18(5):461-4

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

5. 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

6. 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 %

7. 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)

8. 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

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%)

10. 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 ±
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

11. 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 –
0.037
Previous EST
2.713
1.013 – 7.265
0.047

12. 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