Recurrent choledocholithiasis after laparoscopic bile duct exploration: incidence, risk factors, and management strategies.

BACKGROUND

Recurrent common bile duct stone (CBDS) following laparoscopic bile duct exploration (LCBDE) represents a clinically significant long-term complication, with implications for patient morbidity, healthcare utilization, and procedural outcomes. This study aims to quantify the incidence of recurrent CBDS and identify potentially modifiable risk factors in a high-volume referral center

METHODS

A 30-year prospectively maintained database of LCBDE was analyzed. Recurrences were defined by clinical and biochemical suspicion, with or without radiological confirmation, and included non-intervention cases. Electronic records were reviewed in 2020 and 2023 to identify additional episodes not captured in the original database.

RESULTS

Among 1447 patients undergoing LCBDE, 56 (3.8%) developed recurrent choledocholithiasis after a median interval of 24 months (range: 5-220). Twelve patients (21.4%) experienced spontaneous resolution, while 44 patients (78.6%) had 61 confirmed recurrence episodes. Eight resolved with conservative management, while 53 episodes required 65 ERCPs. Multiple recurrences occurred in 13 patients (23.2%). Patients with recurrence were significantly older (median age 72 vs 60 years, p < 0.001), had larger stones (median diameter 10 mm vs 8 mm, p < 0.001), were more likely to have had a difficult LCBDE (64.3% vs 27.8%, p < 0.001), via a choledochotomy (55.4% vs 30.5%, p < 0.001), or required T-tube drainage (37.7% vs 15.1%, p < 0.001).

CONCLUSIONS

Recurrent CBDS occurred in 3.8% of patients who underwent LCBDE (3% confirmed), a rate notably lower than the 4-30% reported after sphincterotomy. Glucagon may aid the spontaneous passage of small stones in suspected recurrence episodes. Multiple recurrences affected 23.2% of patients, warranting consideration of bile acid dissolution therapy. Two modifiable factors significantly reduce recurrence risk: avoiding preoperative sphincterotomy and favoring transcystic over choledochotomy exploration.