Is the Success Rate of Endoscopic Retrograde Cholangiopancreatography (ERCP) ± Sphincterotomy Done for Bile Duct Stones Optimal?

BACKGROUND: Endoscopic Retrograde Cholangiopancreatography (ERCP) is the standard treatment for bile duct stones (BDS). While reported success rates often exceed 80%, the literature rarely distinguishes between success at the index ERCP and cumulative success across multiple procedures. Moreover, definitions of ERCP success vary significantly.

AIM: This study evaluates the index ERCP's success rates according to pre-defined criteria.

METHODS: A retrospective review of all ERCPs performed for BDS before cholecystectomy at University Hospitals Plymouth (2009-2023). Primary outcomes included bile duct clearance at index ERCP, post-procedural complications, stone recurrence, and mortality.

RESULTS: A total of 1,436 patients, median age 72 years (20-94), underwent 1853 ERCPs for BDS. The bile duct cannulation and clearance rates were 93.5% and 70.9%, respectively. The main reasons for procedure failure were incomplete stone removal (12.3%) and anatomical challenges (7.1%). Among the cohort, 22.8% required repeat ERCPs. The complication rate was 4.8% (pancreatitis = 1.7%, biliary sepsis = 1.5%, bleeding = 1.3% and perforation = 0.4%). The BDS recurrence rate was 9.8% and the median time to recurrence was 7 months (1-112). On multivariate analysis, male sex was the only risk factor for stone recurrence (OR:2.242,95%CI:1.304-3.853, P = 0.003). All patients with post-ERCP complications were admitted to the hospital, and their median hospital stay was seven days (1-306). The 90-day mortality rate was 2.1%.

CONCLUSION: In our study, index ERCP achieved stone clearance in 70.9% of cases, with a quarter of patients needing a repeat procedure. Patients should be appropriately consented to and informed of the success rate of ERCP and alternative treatment options, such as intraoperative imaging followed by bile duct exploration and cholecystectomy for surgically fit patients.