Introduction
Periampullary diverticulum (PAD) is ordinarily asymptomatic, which is inspected occasionally during gastroscopy and endoscopic retrograde cholangiopancreatography (ERCP). Previous studies demonstrated inconsistent effect of PAD on ERCP procedures and choledocholithiasis recurrence. Thus, this study was aimed to investigate the impact of different types of PAD on the technical success, post-ERCP complications and the safety of different stone extraction methods, as well as the association of PAD with the recurrence of common bile duct stones (CBDS).
Aims & Methods
The ERCP database (March 2019 to March 2021) in West China Hospital of Sichuan University was retrospectively reviewed. Inclusion criteria were: 1) presence of original duodenal papilla; 2) patients with CBDS. However, patients with the following characteristics were excluded: 1) ERCP for other reasons; 2) absence of original papilla; 3) duodenal ampullary mass; 4) anatomical abnormalities caused by surgery; 5) under 18 years old; 6) incomplete clinical data. In this study, PAD is classified into three types based on the location of the duodenal papilla within the diverticulum (type I), the edge of the diverticulum (type II), and the outside of the diverticulum (type III). The successful cannulation, procedures of ERCP and post-ERCP complications were compared between the PAD group and the non-PAD group, as well as among the different types of PAD groups. The patients with successful stone removal were followed up every 6 months until December 2023 to determine whether PAD was associated with the recurrence of CBDS.
Results
A total of 830 CBDS cases with original duodenal papilla were eventually enrolled, including 239 cases with PAD and 591 cases without PAD. The successful cannulation rate in the PAD group was lower than that in the non-PAD group (96.7% vs. 99.2%, P = 0.013). According to the different types of PAD, the successful cannulation rate of type I PAD was lower compared with non-PAD group (76.9% vs. 99.2%, P<0.001). Additionally, PAD was associated with a wider bile duct diameter (1.55 ± 0.58 vs. 1.37 ± 0.50 mm, P<0.001), larger stone size (1.21 ± 0.68 vs. 0.97 ± 0.54 mm, P<0.001) and a higher rate of endoscopic sphincterotomy (EST) combined with endoscopic papillary balloon dilation (EPBD) (29.0% vs. 15.7%, P<0.001) and mechanical lithotripsy (41.6% vs. 26.5%, P<0.001) during the ERCP procedure. But PAD did not affect the incidence of post-ERCP complications. Of note, PAD group had a higher recurrence rate (18.8% vs. 7.3%, P<0.001) and shorter recurrence-free time (39.9 ± 13.3 vs. 42.8 ± 9.8 months, P = 0.005) compared with non-PAD group during follow-up period. Based on multivariate analysis, the presence of PAD (OR = 3.265, 95%CI: 1.854-5.751) was an independent risk factor for the recurrence of CBDS, after adjusting for age, gender and other factors.
Conclusion
PAD, especially type I PAD, decreased successful cannulation rate and increased the complexity of stone extraction of ERCP in CBDS. However, PAD did not affect the incidence of post-ERCP complications in CBDS, nor did it affect the choice of stone removal methods. PAD was an independent risk factor for the recurrence of CBDS.