Endoscopic Characterization of Giant Choledocholithiasis and Its Correlation With Primary Choledocholithiasis

Gallstone disease is extremely prevalent in Western society, and the prevalence of common bile duct (CBD) stones with concomitant cholelithiasis increases significantly in the elderly. Different variants influence the treatment of this pathological entity, such as the origin of the stones, their location and quantity, comorbidities of the patient, impaction, and size of the lithos, the latter being an independent predictive factor. In most situations, choledocholithiasis can be resolved with endoscopic retrograde cholangiopancreatography (ERCP); however, in complex cases, such as giant choledocholithiasis (GC), advanced surgical, endoscopic, and percutaneous techniques are required to remove gallstones. The main objective was to determine if there is a correlation between GC and primary choledocholithiasis (PC). The secondary objective consisted of describing the endoscopic characterization of GC.

The present study is a cross-sectional and single-center study. The study population consisted of patients of the Institute for Social Security and Services for State Workers (ISSSTE by its acronym in Spanish) Regional Hospital, León, Guanajuato, belonging directly to this center or referred, who required medical attention by the General Surgery/Endoscopy Service with the diagnosis of choledocholithiasis, during the period between January 2017 and December 2022. The Kolmogorov-Smirnov test was used as the normality test. Quantitative variables were reported as mean and standard deviation if the data distribution was normal, in contrast with the expression of data in the median and interquartile range if an abnormal distribution was found. Moreover, the qualitative variables are reported in frequencies or percentages. The Chi-square test was performed as the independence test. The significance level was a 95% confidence interval (p-value 0.05). The effect size was calculated with the odds ratio (OR).

Out of a total of 177 patients, 33 corresponded to PC (18.6%), and 144 belonged to the secondary choledocholithiasis (SC) group (81.4%). Likewise, regarding the dimensions of the lithos, 59 patients (33.3%) presented GC and 118 (66.7%) presented non-GC. Among the 59 patients with GC, 36 were female (61%) and 23 were male (39%). Regarding age, the distribution was as follows: mean 62 ± 12 years, with a minimum value of 29 and a maximum of 88 years. The non-parametric test used to determine the existence or not of a correlation between the variables was Pearson's Chi-square, whose value was 60.509, with a p < 0.001, demonstrating the presence of a correlation between PC and GC. The effect size was corroborated and defined with the OR, whose value was 39.6 (confidence interval (CI) 11.308-139.069).

There is a significant correlation between GC and PC, and it was found that mechanical lithotripsy was the most performed initial extraction method for GC; furthermore, a higher rate of complete endoscopic resolution was found, as well as no complications related to the procedure, which contrasts with the literature. It would be interesting to use the information revealed in the present study as a landmark in future research in this regard.