To assess the necessity to placed CBD stents after stone extraction in patients with co existent gall stones. 

Background:Whether CBD stents should be routinely placed following ductal clearance in patients who also have gallstones remains controversial. Our unit follows a uniform protocol of placing a 7Fr plastic double‑pigtail (DPT) stent in all such patients after stone extraction. Cholecystectomy is subsequently performed either the same day, after 24 hours (most common), within one week, or later based on patient preference. Stents are removed four weeks after cholecystectomy with mandatory fluoroscopic assessment and CBD clearance. This retrospective analysis aimed to determine whether this routine stenting protocol is justified.

Methods: All patients who underwent ERC for CBD stones between 2021 and 2024 were included. Patients with CBD stones on any imaging modality and co‑existent gallstones were analyzed. Standard ERC techniques—including sphincterotomy, large‑balloon sphincteroplasty, and laser lithotripsy—were used for stone extraction. A 7Fr DPT stent was routinely placed post‑extraction; in Type I Mirizzi’s syndrome, a 10Fr stent was used due to frequent cholangitis. Cholecystectomy timing varied per protocol. Stent removal four weeks post‑surgery included fluoroscopy to assess migration, extraction of retained stents, and balloon or basket sweeps to document residual stones. The primary outcomes were spontaneous distal migration of stents and presence of stones at stent removal. Subgroup analysis examined single versus multiple CBD stones and Mirizzi’s syndrome.

Of 1,363 ERCs for stone disease, 1,162 patients (85.3%) had both CBD stones and gallstones. Stents were placed in all 1,162 cases. A total of 1,044 patients (89.8%) returned for stent removal; 118 (10.2%) were lost to follow‑up. Spontaneous stent migration occurred in 209 patients (20.1%), while 835 (79.9%) had retained stents. Among those with retained stents, 149 patients (17.8%) had stones detected during removal.

Subgroup analysis (n = 835):

• Single stone at index ERC: 482 patients (57.7%); stones at removal 39 (8.1%).  

• Multiple stones at index ERC: 274 patients (32.8%); stones at removal 67 (24.5%). 

• Mirizzi’s syndrome: 79 patients (9.5%); stones at removal 42 (53.1%).

Discussion: 

This large retrospective series demonstrates a substantial risk of residual or recurrent CBD stones after cholecystectomy in patients who initially present with CBD stones and gallstones. The likelihood varies significantly with clinical scenario: patients with a single CBD stone had the lowest risk, while those with multiple stones had nearly a quarter incidence of residual stones. The highest risk occurred in Mirizzi’s syndrome, where over half had stones at stent removal. This may be explained by surgical difficulty and frequent failure to extract deeply impacted stones, particularly in centers without routine operative cholangiography or fluoroscopic guidance.

The presence of a dilated CBD that initially allowed stone migration likely persists until after surgery; manipulation of the gallbladder during cholecystectomy can precipitate additional stones into the CBD. Routine stenting ensures unobstructed drainage, facilitates safe interval surgery, and provides an opportunity for definitive duct clearance at the time of stent removal. Double‑pigtail stents are preferred due to a tendency for distal rather than proximal migration, minimizing the need for complex retrieval.

Given the significant rate of stones detected during planned stent removal—ranging from 8% in single‑stone cases to over 50% in Mirizzi’s syndrome—routine placement of a CBD stent following ERC appears justified in patients with gallstones. DPT stents provide higher safety against proximal migration and high spontaneous distal migration, and systematic duct clearance at stent removal is essential to prevent post‑cholecystectomy cholangitis.