Balancing surgical timing and risk stratification to prevent recurrent common bile duct stones after bile duct clearance

Cholecystectomy is recommended for patients with common bile duct (CBD) and gallbladder (GB) stones following the endoscopic removal of CBD stones, based on the survival benefit demonstrated in a meta-analysis.1 The European Society of Gastrointestinal Endoscopy guidelines recommend performing cholecystectomy within two weeks of endoscopic CBD stone removal in patients with CBD and GB stones to reduce the risk of recurrent biliary events.2 However, in clinical practice, cholecystectomy is often delayed because of limited surgical availability, patient comorbidities, or the severity of acute cholecystitis, cholangitis, and pancreatitis. Recurrent biliary events, including acute cholecystitis, CBD stones, acute cholangitis, and acute pancreatitis, can develop during the interval between endoscopic stone removal and cholecystectomy.3

Sumiya et al.4 conducted a retrospective study evaluating the incidence of and risk factors for CBD stone recurrence in patients who underwent endoscopic stone extraction and subsequent cholecystectomy within 180 days of the initial endoscopic procedure without prophylactic biliary stenting. In this study, the CBD stone recurrence rate was 4.1%, and multivariate analysis identified the presence of cystic duct stones as a significant risk factor for CBD stone recurrence (hazard ratio, 15.6; 95% confidence interval, 3.7–66; p<0.001).

Complete stone extraction was confirmed via balloon occlusion cholangiography. However, a meta-analysis showed that peroral cholangioscopy can detect residual CBD stones in up to 27% of cases, even after negative occlusion cholangiography.5 Therefore, the possibility of residual CBD stones in the study by Sumiya et al.4 cannot be entirely excluded. Prospective studies are warranted to assess stone recurrence more accurately by employing highly sensitive diagnostic tools—such as peroral cholangioscopy, endoscopic ultrasound, or magnetic resonance cholangiopancreatography—to confirm complete endoscopic ductal clearance.

The CBD stone recurrence rate in the study by Sumiya et al.,4 in which biliary stenting was not used before cholecystectomy, was only 4.1%; this is substantially lower than the rates of 20.1% and 25.5% reported in two previous studies6,7 that employed endoscopic nasobiliary drainage (ENBD) and prophylactic biliary stenting, respectively. In the study by Sumiya et al.,4 endoscopic retrograde cholangiopancreatography (ERCP) was performed only when cholangitis occurred or when CBD stones were detected on abdominal computed tomography (CT). In contrast, the two previous studies used ENBD cholangiography or ERCP in all patients, likely leading to a higher detection rate of recurrent CBD stones. Therefore, asymptomatic or CT-occult CBD stones may have been missed in the study by Sumiya et al.,4 suggesting that the actual recurrence rate of CBD stones is likely higher than reported. Conversely, as noted by Valvano et al.,8 small residual stones or sludge may pass spontaneously through the papilla into the duodenum in the absence of a biliary stent. A meta-analysis of 4 studies with 755 patients demonstrated no benefit of biliary stent insertion following bile duct clearance in patients scheduled for delayed cholecystectomy performed at least 1 month after endoscopic treatment.

A retrospective study by Satoh et al. demonstrated that plastic stent placement as a bridge to elective cholecystectomy is a significant independent risk factor for biliary tract events—including acute cholecystitis, acute cholangitis, biloma, hepatic abscess, and stent complications requiring re-ERCP—during the waiting period. This suggests that initial stone removal is preferable to minimize preoperative complications, such as acute cholecystitis and cholangitis.9 Well-designed prospective studies are needed to clarify the role of endoscopic biliary drainage in the interval between CBD stone clearance and subsequent cholecystectomy.

Sumiya et al.4 and other previous studies identified cystic duct stones, multiple or large stones, and the use of mechanical lithotripsy as key risk factors for recurrent CBD stones during the interval between endoscopic CBD stone removal and subsequent cholecystectomy.6,7 Therefore, in patients with these risk factors, expedited cholecystectomy should be strongly considered, alongside meticulous monitoring for the development of recurrent biliary events. Because risk factors such as multiple or large stones and the use of mechanical lithotripsy are associated with a higher likelihood of residual CBD stones following endoscopic removal, clinicians should consider using advanced diagnostic modalities—such as endoscopic ultrasound or peroral cholangioscopy—beyond conventional methods to verify complete ductal clearance.

Endoscopic biliary stenting should be selectively considered in patients with high-risk factors for CBD stone recurrence and delayed cholecystectomy following initial endoscopic ductal clearance. Because cystic duct stones are a major driver of CBD stone recurrence, meticulous evaluation is required to detect their presence.

In the study by Sumiya et al.,4 the median interval to CBD stone recurrence was 40 days, with most recurrences occurring before cholecystectomy. Although performing surgery within the recommended two-week window can be challenging in certain clinical scenarios, performing cholecystectomy as soon as possible is imperative to prevent these preoperative events.

In conclusion, timely cholecystectomy should be prioritized to reduce the incidence of recurrent biliary stones following endoscopic ductal clearance in patients with CBD and GB stones. When a delay in cholecystectomy is unavoidable following endoscopic CBD stone clearance, establishing tailored management plans guided by the identified risk factors is crucial to reduce the occurrence of recurrent biliary events. Furthermore, large-scale randomized controlled trials are warranted to clarify the incidence of and risk factors for recurrent biliary stones, as well as the potential role of prophylactic biliary stenting as a bridge to surgery in patients awaiting definitive cholecystectomy.