Ice-breaking sign: A radiological sign influencing the treatment strategies for choledocholithiasis

Choledocholithiasis is a common benign disease of the biliary tract. We identified a particular type of choledocholithiasis characterized by sudden narrowing of the common bile duct at the site of impaction, which caused a marked increase in surgical difficulty and risk compared to treatment for typical choledocholithiasis. This phenomenon has not been described in previous studies.

To propose the ice-breaking sign and evaluate its influence on treatment strategies for choledocholithiasis.

Using a retrospective case-control study design, patients who were diagnosed with common bile duct stones and admitted to the Emergency Department of Peking University Third Hospital between January 2018 and December 2023 were included. Propensity score matching was used to match cases and controls. Univariate analysis was conducted to assess the differences in clinical data between the two groups of patients.

There were no significant differences in the baseline data between the two groups, except for higher incidence of jaundice, alkaline phosphatase and total bilirubin in the ice-breaking sign group. Compared to the control group, the ice-breaking sign group had lower success rates for endoscopic retrograde cholangiopancreatography (25.0% vs 81.8%, P = 0.006) and laparoscopic common bile duct exploration (69.4% vs 93.8%, P = 0.007), longer operation time (148.04 ± 60.55 minutes vs 106.15 ± 35.21 minutes, P = 0.001), higher likelihood of T-tube placement (62.2% vs 31.3%, P = 0.016) and using lithotripsy techniques during surgery (29.7% vs 0%, P = 0.001), more intraoperative bleeding [25.0 (20.0-50.0) mL vs 10.0 (10.0-20.0) mL, P < 0.001] and longer postoperative hospital stay [6.50 (5.0-9.0) days vs 5.50 (3.0-6.50) days, P = 0.002]. The ice-breaking sign group showed significantly more dilatation in the proximal than distal bile duct.

The ice-breaking sign, a newly identified radiological phenomenon, may influence therapeutic decisions in choledocholithiasis, suggesting laparoscopic common bile duct exploration as the preferred approach over endoscopic retrograde cholangiopancreatography in patients exhibiting this sign.