Before the introduction of endoscopic sphincterotyomy(EST), open cholecystectomy and exploration of the common bile duct has been standard treatment of the patients with cholecystocholedocholithiasis. In 1974 Claasen and Kawai introduced endoscopic papillotomy (EST), Endoscopic retrograde cholangiopancreatography (ERCP) is widespread used for removal of CBD stones in the following 40 years. ERCP for stone removal are generally considered both safe and effective, but several complications occur and late complication like recurrence of CBD stone is a difficult problem for management. So I will review the recurrent rate and risk factors of recurrent CBD stone, the management of recurrent CBD stone and several drainage procedures.
1. The recurrent rate and risk factors of recurrent CBD stone
The recurrence of CBD stones which is defined CBD stones diagnosed more than 6month after ERCP) is a late complication following endoscopic management. Rates of recurrence in the literature vary from 4 to 24%. Park et al reported a nationwide population-based study of CBD stone recurrence after endoscopic stone removal in Korea, and described that first CBD stone recurrence occurred in 11.3%, however 2nd and 3rd was 23.4% and 33.4%, so they recommended regular f-up for patients with recurrent stones. The putative mechanism for stone recurrences still be debated. There are two dominating theories 1) Endobiliary bile stasis 2) Duodenal - biliary reflux. There are several risk factors of recurrent CBD stone 1) Duodenal-biliary reflux 2) Acute distal CBD angulation 3) Prior EST 4) Intact gallbladder with stones in situ 5) Biliary stricture 6) Papillary stenosis 7) Large stone size 8) Old age 9) Bacterial infection/colonization of the CBD. Bacterial count 10) Multiple number of sessions to clear duct at first presentation 12) Excessive dilation of the CBD >15mm 13) Periampullary diverticulum. Among the above factors, excessive dilation of the CBD >15mm and periampullary diverticulum are most important risk factors.
2. The management of recurrent CBD stone
The main options for management of recurrent CBD stone are Endoscopic retrograde cholangiopancreatography (ERCP) and Surgery (open CBDE/ laparoscopic CBDE), and other options are dissolving solution, percutaneous radiologic interventions. The determents of treatment include size and location of stone, diameter of CBD, post cholecystectomy status of the patients, presence of stricture and risk assessment of the patient-age and associated systemic disease. Endoscopic stone extraction is the first choice procedure, however surgery is reserved for patients in whom the ampulla cannot be cannulated and stone extraction is incomplete or failed. Laparoscopic CBDE is the main procedure for recurrent CBD stone and drainage procedures (choledochojejunostomy and choledochoduodenostomy) apply in selected patients. Drainage procedure apply in highly selected patients whom had major CBD dilatation, CBD stricture, stenosis of a previous sphincterotomy or anastomosis, or associated chronic pancreatitis and recurrent primary bile duct stones.

3. Referecce
1) Park BK, Seo JH, Jeon HH, Choi JW, Won SY, Cho YS, et al. A nationwide population-based study of common bile duct stone recurrence after endoscopic stone removal in Korea Gastroenterol. 2017 Nov 30.
2) Konstantakis C, Triantos C, Theopistos V, Theocharis G, Maroulis I, Diamantopoulou G, et al. Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones World J Gastrointest Endosc 2017 January 16; 9(1): 26-33