Effect of Saline Irrigation to DEcrease Rate Of Residual Common Bile Duct Stones

Common Bile Duct Gallstones Clinical Trial

— SIDEROD  

Official title:

Effect of Saline Irrigation to Decrease Rate of Residual Common Bile Duct Stones

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT01425177
• Other study ID #: LSH 0909
• Status: Recruiting
• Phase: Phase 3
• First received: August 26, 2011
• Last updated: August 26, 2011
• Start date: August 2011
• Est. completion date: December 2012

Study information

• Verified date: August 2011
• Source: Seoul National University Hospital
• Contact: Sang Eon Jang, M.D
• Phone: +82-10-7479-6271
• Email: medimax2[@]naver.com
• Is FDA regulated: No
• Health authority: Korea: Food and Drug Administration
• Study type: Interventional

Clinical Trial Summary

In recent years, endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones.

After procedures, there are some complications such as stone recurrence, papillary stenosis, cholangitis and liver abscess. These recurrent symptomatic bile duct stones, despite increasing experience and success with the procedure, occur in 4% to 24% of patients.

Gallbladder stone, pneumobilia and many other various factors are known to be associated with CBD stone recurrence. Lithotripsy was also related to the development of recurrent stones. It is natural that small stone fragments left after lithotripsy may act as nidi for stone recurrence.

Small remaining stone could not be completely detected only using ERCP stone removal and remaining stone removal can reduce residual and recurrent stones. Saline irrigation was effective immediately after ERCP stone removal to remove remaining small stones.

Saline irrigation has many advantages such as easy to treatment during ERCP stone removal, almost no additional cost and rare side effect. This study The authors expect this study is a remarkable role of ERCP stone removal procedure.

Description:

CBD stones are defined as the occurrence of stones in the bile ducts. CBD stone usually causes biliary pain and jaundice, whereas obstruction that develops gradually over several months may manifest initially as pruritus or jaundice alone.

Unlike stones in the gallbladder, CBD stones cause symptoms, tend to present as life-threatening complications such as cholangitis and acute pancreatitis. Given its propensity to result in these serious complications, choledocholithiasis warrants treatment in nearly all cases In 2010, guideline for the risk and treatment of choledocholithiasis was published. The most predictive variables seem to be cholangitis, a bilirubin level higher than 1.7 mg/dL, and a dilated CBD on US. The presence of 2 or more of these variables results in a high probability of a CBD stone. Advanced age (older than 55 years), elevation of a liver biochemical test result other than bilirubin, and pancreatitis are less robust predictors for choledocholithiasis.

There are various ways of non invasive imaging diagnosis of CBD stone. The sensitivity of transabdominal US and conventional computed tomography (CT) in the detection of biliary stones is variable, ranging from 20% to 80% and from 23% to 85%, respectively. MRCP had sensitivity 92-93%, specificity 97-98%. Although MRCP is most excellent in diagnosis, the sensitivity is reduced 33-71% at diagnosis of small stones(less than 5mm) An ERCP has traditionally been considered the evaluation of biliary-tract diseases. This modality is very sensitive (90%) and specific (98%) in detecting CBD stone. EUS for the diagnosis of CBD stone reports widely varying sensitivities of 71% to 100% and specificities of 67% to 100%. Some papers report that intraductal ultrasound(IDUS) is very sensitive(97-100%). However, this is expensive and requires the fully-experienced endoscopist, so, it is difficult to use that.

In recent years, endoscopic sphincterotomy and stone extraction are standard procedures for the removal of bile duct stones. After procedures, there are some complications such as stone recurrence, papillary stenosis, cholangitis and liver abscess. These recurrent symptomatic bile duct stones, despite increasing experience and success with the procedure, occur in 4% to 24% of patients.

Retained stone is defined as incomplete stone removal during ERCP, otherwise recurrent stone is defined as recurrence stone after complete stone removal. A criterion to distinguish between the two is stones rediscovery time after ERCP stone removal. Typically, bile duct stones found 6 months or more after endoscopic retrograde cholangiopancreatography (ERCP) generally are considered recurrent, as opposed to retained Gallbladder stone, pneumobilia and many other various factors are known to be associated with CBD stone recurrence. Lithotripsy was also related to the development of recurrent stones. It is natural that small stone fragments left after lithotripsy may act as nidi for stone recurrence.

For this reason, many studies that reduce the residual and recurrence CBD stones have been performed. Before procedures, MRCP, CT and EUS are performed to identify the exact location of stones. Many studies demonstrated that residual stone clearance with ENBD, EUS or IDUS immediately after ERCP stone removal are useful in reducing the recurrence.

However, cholangiogram with ENBD or using EUS after ERCP stone removal increases the duration of hospital stay, cost and the patient's discomfort. Until now, non-invasive, time reduced, cheap and simply way was unknown.

Recently, two different studies were published. Using IDUS could effectively find residual CBD stones that persisted after EST and balloon and basket extraction. Furthermore, normal saline irrigation of CBD after stone removal appeared useful in clearing residual small stones. These procedures could reduce the retained and recurrent stone Another study showed that additional IDUS to confirm complete stone clearance after ERCP with basket stone removal significantly decreases the early recurrence rate of common bile duct stones.

These studies demonstrated that small remaining stone could not be completely detected only using ERCP stone removal and remaining stone removal can reduce residual and recurrent stones. Saline irrigation was effective immediately after ERCP stone removal to remove remaining small stones .

However, prospective study that saline irrigation without EUS or IDUS can reduce recurrent CBD stones after ERCP stone removal does not yet. Saline irrigation has many advantages such as easy to treatment during ERCP stone removal, almost no additional cost and rare side effect. This study The authors expect this study is a remarkable role of ERCP stone removal procedure.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 160
• Est. completion date: December 2012
• Est. primary completion date: December 2012
• Accepts healthy volunteers: Accepts Healthy Volunteers
• Gender: Both
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• The patients were treated with CBD stone removal during therapeutic ERCP after finding CBD stones with CT, ultrasound or MRCP.

• The patients were treated with CBD stone removal during diagnostic ERCP because of cholangitis or cholecystitis.

Exclusion Criteria:

• Hemodynamic instability

• Younger than 18

• Mental illness

• Received previous CBD stone removal

• Hemolytic anemia, IHD stone, parasites in hepatobiliary system

• Genetic, autoimmune, congenital biliary disorder

• Liver or biliary surgery except cholecystectomy

• Pancreatic cancer, cholangiocarcinoma, ampulla of vater cancer

Study Design

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Single Blind (Subject), Primary Purpose: Prevention

Related Conditions & MeSH terms

• Common Bile Duct Gallstones

Intervention

Procedure:
• Normal Saline Irrigation
After removing CBD stones with the ERCP, 200ml of the normal saline solution was irrigated into the common bile duct.

Locations

Country	Name	City	State
Korea, Republic of	Seoul National University Bundang Hospital	Seoungnam	Gyeonggi-do

Sponsors (1)

Lead Sponsor	Collaborator
Seoul National University Hospital

Country where clinical trial is conducted

Korea, Republic of, 

References & Publications (16)

Ando T, Tsuyuguchi T, Okugawa T, Saito M, Ishihara T, Yamaguchi T, Saisho H. Risk factors for recurrent bile duct stones after endoscopic papillotomy. Gut. 2003 Jan;52(1):116-21. — View Citation

Ang TL, Teo EK, Fock KM, Lyn Tan JY. Are there roles for intraductal US and saline solution irrigation in ensuring complete clearance of common bile duct stones? Gastrointest Endosc. 2009 Jun;69(7):1276-81. doi: 10.1016/j.gie.2008.10.018. Epub 2009 Feb 26. — View Citation

ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, Anderson MA, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Strohmeyer L, Dominitz JA. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc. 2010 Jan;71(1):1-9. doi: 10.1016/j.gie.2009.09.041. — View Citation

Boix J, Lorenzo-Zúñiga V, Añaños F, Domènech E, Morillas RM, Gassull MA. Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula. Surg Laparosc Endosc Percutan Tech. 2006 Aug;16(4):208-11. — View Citation

Boraschi P, Neri E, Braccini G, Gigoni R, Caramella D, Perri G, Bartolozzi C. Choledocolithiasis: diagnostic accuracy of MR cholangiopancreatography. Three-year experience. Magn Reson Imaging. 1999 Nov;17(9):1245-53. — View Citation

Cheon YK, Lehman GA. Identification of risk factors for stone recurrence after endoscopic treatment of bile duct stones. Eur J Gastroenterol Hepatol. 2006 May;18(5):461-4. Review. — View Citation

Cotton PB, Geenen JE, Sherman S, Cunningham JT, Howell DA, Carr-Locke DL, Nickl NJ, Hawes RH, Lehman GA, Ferrari A, Slivka A, Lichtenstein DR, Baillie J, Jowell PS, Lail LM, Evangelou H, Bosco JJ, Hanson BL, Hoffman BJ, Rahaman SM, Male R. Endoscopic sphincterotomy for stones by experts is safe, even in younger patients with normal ducts. Ann Surg. 1998 Feb;227(2):201-4. — View Citation

Das A, Isenberg G, Wong RC, Sivak MV Jr, Chak A. Wire-guided intraductal US: an adjunct to ERCP in the management of bile duct stones. Gastrointest Endosc. 2001 Jul;54(1):31-6. — View Citation

Duensing RA, Williams RA, Collins JC, Wilson SE. Managing choledocholithiasis in the laparoscopic era. Am J Surg. 1995 Dec;170(6):619-23. — View Citation

Einstein DM, Lapin SA, Ralls PW, Halls JM. The insensitivity of sonography in the detection of choledocholithiasis. AJR Am J Roentgenol. 1984 Apr;142(4):725-8. — View Citation

Keizman D, Shalom MI, Konikoff FM. An angulated common bile duct predisposes to recurrent symptomatic bile duct stones after endoscopic stone extraction. Surg Endosc. 2006 Oct;20(10):1594-9. Epub 2006 Jul 20. — View Citation

Miller FH, Hwang CM, Gabriel H, Goodhartz LA, Omar AJ, Parsons WG 3rd. Contrast-enhanced helical CT of choledocholithiasis. AJR Am J Roentgenol. 2003 Jul;181(1):125-30. — View Citation

Soto JA, Alvarez O, Múnera F, Velez SM, Valencia J, Ramírez N. Diagnosing bile duct stones: comparison of unenhanced helical CT, oral contrast-enhanced CT cholangiography, and MR cholangiography. AJR Am J Roentgenol. 2000 Oct;175(4):1127-34. — View Citation

Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008 Feb;67(2):235-44. doi: 10.1016/j.gie.2007.09.047. — View Citation

Tseng LJ, Jao YT, Mo LR, Lin RC. Over-the-wire US catheter probe as an adjunct to ERCP in the detection of choledocholithiasis. Gastrointest Endosc. 2001 Dec;54(6):720-3. — View Citation

Tsuchiya S, Tsuyuguchi T, Sakai Y, Sugiyama H, Miyagawa K, Fukuda Y, Ando T, Saisho H, Yokosuka O. Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy. J Gastroenterol Hepatol. 2008 Oct;23(10):1590-5. doi: 10.1111/j.1440-1746.2008.05458.x. Epub 2008 Jun 12. — View Citation

* Note: There are 16 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Retained CBD stones	CT or USG; Symptomatic choledocholithiasis	From 3 to 6 months after procedure	No
Secondary	Recurrent CBD Stones	CT, USG; Symptomatic choledocholithiasis	Over 6months after procedure	No
Secondary	Cholangitis	- Fever, RUQ pain, Jaundice	Over 6months after procedure	No

External Links

•   Korea Food and Drug Administration
•   Seoul National University Bundang Hospital
•   Seoul National University College of Medicine