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Gupta P, Singla V, Singh P, Madan K, Kaalia S, Shawl MR, Goel A, Garg P, Bhargava R. Early cholangioscopy-guided lithotripsy for clearance of biliary stones associated with narrow lower bile duct. Endosc Int Open 2025; 13:a25524629. [PMID: 40230566 PMCID: PMC11996019 DOI: 10.1055/a-2552-4629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2024] [Accepted: 01/26/2025] [Indexed: 04/16/2025] Open
Abstract
Background and study aims Stones larger than the distal common bile duct (CBD) are difficult to remove with conventional techniques. Large papillary balloon dilatation (> 12 mm) of the biliary sphincter is an effective technique for stone removal but is associated with risk of leak in patients with narrower lower CBD. Mechanical or cholangioscopy-guided lithotripsy has been used in this situation for clearance of the bile duct. In the present study, we report outcomes of early cholangioscopy-guided lithotripsy in patients with narrow lower CBD compared with stone size. Patients and methods The present study is a retrospective analysis of prospectively collected data from all patients with large proximal stones with a narrow lower bile duct who underwent digital cholangioscopy and electrohydraulic lithotripsy (EHL). Outcomes were proportion of patients with complete bile duct clearance after the first session of electrohydraulic lithotripsy, mean number of EHL sessions for complete clearance, and complications. Results Eighty-one patients with mean age 54 ± 17 years underwent digital cholangioscopy and EHL. Mean stone size was 14.02 ± 3.5 mm and 71 patients (87.7%) had a stone only in the bile duct. Three (3.7%) and seven patients (8.6%) had stones also in the cystic duct and intrahepatic ducts, respectively. Balloon sphincteroplasty never exceeding distal CBD size was performed in 12 patients (14.8%). Complete stone clearance was achieved in 78 patients (96.3%) after a single session. Mean number of EHL sessions were 1.04 ± 0.19. Three patients developed mild adverse events, which were managed conservatively. Conclusions Early upfront digital cholangioscopy with EHL has high efficacy and safety for stone clearance after a single session in patients with narrow distal CBD.
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Affiliation(s)
- Pankaj Gupta
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Vikas Singla
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pankaj Singh
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Kaushal Madan
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Shivam Kaalia
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Muzaffer Rashid Shawl
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Akash Goel
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Pallavi Garg
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
| | - Richa Bhargava
- Institute of Liver and Gastrointestinal Sciences, Max Super Speciality Hospital Saket, New Delhi, India
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Smirniotopoulos JB, Latich I, Nezami N. Advancing biliary stone management: percutaneous transhepatic endoscopic holmium laser lithotripsy for treatment of cholangiolithiasis and choledocholithiasis. Eur Radiol 2024; 34:7173-7175. [PMID: 38980415 DOI: 10.1007/s00330-024-10870-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/03/2024] [Accepted: 06/11/2024] [Indexed: 07/10/2024]
Affiliation(s)
- John B Smirniotopoulos
- Division of Vascular and Interventional Radiology, Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, USA
- Georgetown University School of Medicine, Washington, DC, USA
| | - Igor Latich
- Division of Interventional Radiology, Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Nariman Nezami
- Division of Vascular and Interventional Radiology, Department of Radiology, Medstar Georgetown University Hospital, Washington, DC, USA.
- Georgetown University School of Medicine, Washington, DC, USA.
- Lombardi Comprehensive Cancer Center, Washington, DC, USA.
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Hu A, Eng N, Pauli EM, Lyn-Sue J, Haluck R, Winder JS. Initial Experience with Disposable Single-Use Cholangioscope During Laparoscopic Common Bile Duct Exploration. J Laparoendosc Adv Surg Tech A 2024; 34:877-881. [PMID: 39235341 DOI: 10.1089/lap.2023.0451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024] Open
Abstract
Introduction: For patients with choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) is more cost effective than endoscopic retrograde cholangiopancreatography (ERCP) and results in shorter hospital length of stay. As LCBDE can be technically challenging to perform, utilizing a disposable single-use cholangioscope (DSUC) for LCBDE through a cystic ductotomy has several advantages, such as potentially avoiding a choledochotomy and expanding access to cholangioscopes as a DSUC is disposable and does not require infrastructure for cleaning or maintenance. Methods: An IRB-approved, retrospective chart review from 2021 to 2023 was conducted for patients who underwent concurrent laparoscopic cholecystectomy (LC) and LCBDE with a DSUC (SpyGlass™ Discover, Boston Scientific, Natick, MA) for the management of choledocholithiasis diagnosed either preoperatively or during intraoperative cholangiogram (IOC). Primary endpoint was successful clearance of biliary duct stones. Results: Twelve patients with a mean age of 55.3 years (SD ±13.9) and mean body mass index of 33.8 (SD ±10.8) were found to have filling defects on IOC for LC and underwent LCBDE with DSUC. Of these, 10 patients had stones. Complete stone clearance was achieved in all 10 patients with various stone extraction maneuvers. The mean operative time was 189 minutes (SD ±63.6) and mean hospital length of stay postoperatively was 1 day (SD ±.8). Mean length of follow-up postoperatively was 26.9 (SD ±16.0) days. There were no intraoperative complications, no need for repeat procedures, and only one postoperative complication involving a superficial surgical site infection requiring oral antibiotics. Conclusions: LCBDE with a DSUC is safe and efficacious for clearing stones and identifying pathology of the CBD. Familiarity with this device is especially useful for surgeons who want to simultaneously manage choledocholithiasis at the same time as cholecystectomy to reduce hospital stay and overall cost.
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Affiliation(s)
- Antoinette Hu
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Nina Eng
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Eric M Pauli
- Department of Minimally-Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Jerome Lyn-Sue
- Department of Minimally-Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Randy Haluck
- Department of Minimally-Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Joshua S Winder
- Department of Minimally-Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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Matsumi A, Matsumoto K, Yamazaki T, Horiguchi S, Tsutsumi K, Kato H, Okada H. Successful removal of an uncovered metallic stent using peroral direct cholangioscopy and the stent-in-stent technique. Endoscopy 2022; 54:E860-E861. [PMID: 35668658 PMCID: PMC9735329 DOI: 10.1055/a-1838-3553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Akihiro Matsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Tatsuhiro Yamazaki
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Hospital, Okayama, Japan
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Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques. Medicina (B Aires) 2022; 58:medicina58010120. [PMID: 35056428 PMCID: PMC8779004 DOI: 10.3390/medicina58010120] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/14/2022] Open
Abstract
Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.
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Hao J, Huang X. The Status and Development of Oral Choledochoscopy Diagnosis and Treatment of Biliary Tract Diseases. Int J Gen Med 2021; 14:4269-4277. [PMID: 34393506 PMCID: PMC8360357 DOI: 10.2147/ijgm.s317484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/14/2021] [Indexed: 12/12/2022] Open
Abstract
Choledochoscopy technology has realized the direct observation of bile duct lesions, and can be loaded with a variety of special accessories to perform the corresponding diagnosis and treatment operations, and has become an important means for the diagnosis of unexplained bile duct stricture and treatment of refractory bile duct stones. With the further enhancement of the imaging quality and operability, the clinical application of choledochoscopy has gradually expanded to the precise positioning of cholangiocarcinoma before surgical resection, the drainage of the gallbladder through the nipple, the removal of the displaced bile duct stent and other fields. This paper briefly reviewed the historical evolution of choledochoscopy and reviewed the latest clinical advances of oral choledochoscopy in the diagnosis and treatment of biliary tract diseases.
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Affiliation(s)
- Jinyong Hao
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
| | - Xiaojun Huang
- Department of Gastroenterology, Lanzhou University Second Hospital, Lanzhou, People's Republic of China.,Gansu Provincial Digestive Endoscopy Engineering Research Center, Lanzhou, People's Republic of China
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Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches. World J Gastroenterol 2021; 27:4536-4554. [PMID: 34366622 PMCID: PMC8326257 DOI: 10.3748/wjg.v27.i28.4536] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/02/2021] [Accepted: 06/25/2021] [Indexed: 02/06/2023] Open
Abstract
Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.
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Affiliation(s)
- Pasquale Cianci
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
| | - Enrico Restini
- Department of Surgery and Traumatology, Hospital Lorenzo Bonomo, Andria 76123, Italy
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Lesmana CRA, Paramitha MS, Lesmana LA. Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery. World J Gastrointest Endosc 2021; 13:198-209. [PMID: 34326941 PMCID: PMC8311469 DOI: 10.4253/wjge.v13.i7.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/18/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
Common bile duct (CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone (larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation (EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta 10430, DKI, Indonesia
- Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta 12950, DKI, Indonesia
| | - Maria Satya Paramitha
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Universitas Indonesia, Jakarta 10430, DKI, Indonesia
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One-Step Multichannel Percutaneous Transhepatic Cholangioscopic Lithotripsy Applied in Bilateral Hepatolithiasis. World J Surg 2021; 44:1586-1594. [PMID: 31993722 DOI: 10.1007/s00268-020-05368-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcomes of one-step multichannel percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) with traditional PTCSL in the treatment of bilateral hepatolithiasis. METHODS From February 2011 to June 2015, 156 patients with bilateral hepatolithiasis received surgical treatment in our department. Among these patients, 81 received one-step multichannel PTCSL (group A), and the remaining 75 received traditional PTCSL (group B). RESULTS Compared with group B, group A was characterized by a significantly shorter operation time (83.7 ± 28.5 min vs 118.1 ± 41.5 min; P = 0.000), hospital stay (11.1 ± 3.4 d vs 17.8 ± 5.6 d; P = 0.034), and postoperative hospital stay (6.9 ± 3.1 d vs 9.6 ± 4.5 d; P = 0.026). In addition, the immediate clearance (62.9% vs 45.3%, P = 0.027) and final clearance (90.1% vs 78.7%, P = 0.048) rates were higher in group A than in group B. During the follow-up period, stone recurrence was significantly less common in group A than in group B (13.6% vs 26.7%, P = 0.041). Multivariate Cox analysis showed that the PTCSL method (HR = 2.32, 95% confidence interval [CI] = 1.09-4.90, P = 0.028), bilateral biliary stricture (HR = 4.17, 95% CI = 1.73-10.03, P = 0.001), and stones located in segments I (HR = 7.75, 95% CI = 3.67-16.38, P = 0.000) were independent predictors of recurrence. CONCLUSIONS Compared with traditional PTCSL, one-step multichannel PTCSL was more efficient and effective in the treatment of bilateral hepatolithiasis.
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Galetti F, Moura DTHD, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGHD. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2020; 33:e1491. [PMID: 32609255 PMCID: PMC7325696 DOI: 10.1590/0102-672020190001e1491] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/19/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. AIM To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. METHODS Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. RESULTS Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). CONCLUSIONS For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.
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Affiliation(s)
- Facundo Galetti
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Diogo Turiani Hourneaux de Moura
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
- Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Igor Braga Ribeiro
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Mateus Pereira Funari
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Martin Coronel
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Amit H Sachde
- Divisão de Gastroenterologia, Hepatologia e Endoscopia, Brigham and Women´s Hospital, Harvard Medical School, Boston, Massachusetts, EUA
| | - Vitor Ottoboni Brunaldi
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tomazo Prince Franzini
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Wanderley Marques Bernardo
- Unidade de Endoscopia Gastrointestinal, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brasil
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Abstract
PURPOSE OF REVIEW Hepatolithiasis is a disease characterized by intrahepatic stone formation. In this article, we review the features of this disease and explore the established and emerging treatment modalities. RECENT FINDINGS Recent reports show an increasing prevalence of hepatolithiasis, likely owed to increased immigration and shifts in the Western diet. New pharmacotherapy options are limited and are often only supportive. Endoscopic intervention still cruxes on removal of impacted stones, though new techniques such as bile duct exploratory lithotomy and lithotripsy continue to advance management. Although hepatectomy of the effected portion of the liver offers definitive therapy, alternative less invasive modalities such as combined endoscopic/interventional radiology modalities have been utilized in select patients. Additionally, liver transplant serves as an option for otherwise incurable hepatolithiasis with coexisting liver dysfunction. Multiple emerging pharmacologic and procedural interventions may provide novel treatment for hepatolithiasis. While definitive therapy remains resection of affected liver segments, these modalities offer hope for less invasive approaches in the future.
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Wen XD, Ren LN, Wang T, Wang XJ, Navarro-Alvarez N, Li LP, Liu WH. Combined lithotripsy of mechanical clamping and electrohydraulics in facilitating endoscopic management of refractory residual biliary calculi after surgery. Sci Rep 2020; 10:2604. [PMID: 32054869 PMCID: PMC7018823 DOI: 10.1038/s41598-020-58394-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 01/09/2020] [Indexed: 12/02/2022] Open
Abstract
Although postoperative cholangioscopy (POC) guided electrohydraulic lithotripsy (EHL) is considered to be a conventional technique for residual biliary calculi, its efficacy still needs to be improved to fit in the managemet of refractory calculi. This study evaluated the efficacy and safety of combined lithotripsy of mechanical clamping and electrohydraulics in fragmentation and removal of refractory calculi. Totally, 281 patients, who suffered from residual biliary calculi after hepatectomy and underwnet POC from August 2016 to June 2018 were involved. The first 128 patients were subjected to conventional EHL, and later consective 153 to combined lithotripsyof mechanical clamping and EHL. Perioperative data, technical information, treatment outcomes and follow-up results were collected. Clinical characteristics were statistically comparable (P > 0.05). The overall POC interventional sessions (2.0 ± 0.65 vs. 2.9 ± 1.21 sessions), average operating time (99.1 ± 34.88 vs. 128.6 ± 72.87 minutes), incidence of intraoperative hemobilia (4.58% vs. 10.93%), cholangitis (6.54% vs. 14.06%), postoperative complications (10.45% vs. 21.87%), T-tube retaining time after first POC (20.7 ± 5.35 vs. 28.1 ± 8.28 days), and treatment costs ($2375 ± 661.72 vs. $3456.7 ± 638.07) were significantly lower in the combined lithotripsy group than those in the EHL group (P < 0.05). There were no differences between the two groups in calculi recurrence at half-a year, or one year follow-up. In conclusion, combined lithotripsy of mechanical clamping and electrohydraulics can safely and effectively benefit postoperative patients along with refractory residual biliary calculi.
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Affiliation(s)
- Xu-Dong Wen
- Department of Gastroenterology, Chengdu First People's Hospital, Chengdu, Sichuan Province, 610016, China
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, 610072, China
| | - Li-Na Ren
- The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China
| | - Tao Wang
- The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China
| | - Xiao-Juan Wang
- The General Hospital of Western Theater Command, Chengdu, Sichuan Province, 610083, China
| | - Nalu Navarro-Alvarez
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, 02138, USA
| | - Liang-Ping Li
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, 610072, China
| | - Wei-Hui Liu
- Department of Gastroenterology and Hepatology, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan Province, 610072, China.
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Sandha J, van Zanten SV, Sandha G. The Safety and Efficacy of Single-Operator Cholangioscopy in the Treatment of Difficult Common Bile Duct Stones after Failed Conventional ERCP. J Can Assoc Gastroenterol 2019; 1:181-190. [PMID: 31294359 PMCID: PMC6530813 DOI: 10.1093/jcag/gwy021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Common bile duct (CBD) stones are extracted with a basket or balloon during ERCP with sphincterotomy. However, some stones are difficult to extract by conventional means. Cholangioscopy with lithotripsy is a modality to treat these difficult stones. We describe the clinical efficacy of single-operator per oral cholangioscopy (SOPOC) for difficult stones and discuss cost savings by avoiding surgical intervention. Methods Retrospective chart review was performed for all patients referred for difficult CBD stones. Clinical success was defined as clearing the duct of all stones. The cost of cholangioscopy (in $CDN) was calculated by adding all costs associated with the procedure(s), surgery, hospital stay or treatment of adverse events. This cost was compared with the projected cost of surgical bile duct exploration. Results A total of 51 patients (35 female) with a mean age of 66 years underwent 58 SOPOC procedures. Median procedure time was 67 minutes (95% CI, 61.5–73.5). The CBD was successfully cleared in 47 of 51 patients (93%). Minor adverse events were seen in seven patients (14%). The actual average per procedure cost was $4555±$2647. This compares with a projected cost of $7766 and $6175 for open and laparoscopic bile duct exploration, with a cost-per-case saving of $3210 and $1619, respectively. Conclusion SOPOC with lithotripsy is highly effective and safe for the treatment of difficult common bile duct stones. In addition, significant cost savings may be realized by avoiding surgical bile duct exploration.
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Affiliation(s)
- Jaskiran Sandha
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Gurpal Sandha
- Division of Gastroenterology, University of Alberta Hospital, Edmonton, Alberta, Canada
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Haseeb A, Freeman ML. Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones. ACTA ACUST UNITED AC 2019; 17:221-230. [PMID: 30945095 DOI: 10.1007/s11938-019-00234-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW To review the current literature focusing on the indications, efficacy, and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) with or without endoscopic sphincterotomy (EST) in the treatment of bile duct stones. • EPBD without EST is associated with a higher risk of post-procedural pancreatitis and lower rate of stone clearance than EST alone. • EPBD without EST should be at least 2 min in duration, and placement of a pancreatic stent and other measures to reduce pancreatitis risk should be considered. • EPBD without EST is most useful to reduce risk of bleeding in patients with coagulopathy. • EPLBD combined with EST can be used as an alternative or adjunct to mechanical lithotripsy in the removal of large or difficult bile duct stones. • EPLBD combined with EST results in fewer complications than EST alone for removal of bile duct stones.
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Affiliation(s)
- Abdul Haseeb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Martin L Freeman
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota, MMC 36, 420 Delaware St SE, Minneapolis, MN, 55455, USA.
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Salerno R, Mezzina N, Ardizzone S. Endoscopic retrograde cholangiopancreatography, lights and shadows: Handle with care. World J Gastrointest Endosc 2019; 11:219-230. [PMID: 30918587 PMCID: PMC6425281 DOI: 10.4253/wjge.v11.i3.219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/21/2019] [Accepted: 03/11/2019] [Indexed: 02/06/2023] Open
Abstract
The role of endoscopic retrograde cholangiopancreatography (ERCP) has dramatically changed in the last years, mainly into that of a therapeutic procedure. The treatment of benign biliary disease, like “difficult” choledocolithiasis, with endoscopic papillary large balloon dilation combined with endoscopic sphinterotomy has proven an effective and safe technique. Moreover, safety in ERCP has improved as well, with the prevention of post-ERCP pancreatitis and patient-to-patient transmission of infections. The advent of self-expandable metal stenting has radically changed the management of biliopancreatic malignant strictures, while the role for therapy of benign strictures is still controversial. In addition, cholangioscopy (though the direct visualization of the biliopancreatic ductal system) has allowed for characterization of indeterminate biliary strictures and facilitated rescue therapy of large biliary stones deemed removable. Encouraging data from tissue ablation techniques, such as photodynamic therapy and radiofrequency ablation, need to be confirmed by large sample size clinical controlled trials. On the other hand, we have no drug-coated stents yet available to implant and evidence for the use of biodegradable stents is still weak. The competency and privileging of ERCP and endoscopic ultrasonography have been analyzed longer but the switch between the two procedures, at the same time, is becoming ordinary; as such, the endoscopist interested in this field should undergo parallel edification through training plans. Finally, the American Society for Gastrointestinal Endoscopy’s statement on non-anesthesiologist administration of propofol for gastrointestinal endoscopy is not actually endorsed by the European Society of Anaesthesiology, having many medical-legal implications in some European countries.
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Affiliation(s)
- Raffaele Salerno
- Gastroenterology and Digestive Endoscopy Unit, ASST Fatebenefratelli Sacco, Milan 20121, Italy
| | - Nicolò Mezzina
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco-Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
| | - Sandro Ardizzone
- Gastrointestinal Unit, ASST Fatebenefratelli Sacco - Department of Biochemical and Clinical Sciences "L. Sacco", University of Milan, Milano 20100, Italy
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Nasser A, Bill K, Barawi M. Lumen-apposing metal stent-assisted electrohydraulic lithotripsy and mechanical lithotripsy for cholelithiasis in a nonsurgical patient. VideoGIE 2019; 4:159-160. [PMID: 31016275 PMCID: PMC6470361 DOI: 10.1016/j.vgie.2018.12.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Abdulla Nasser
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan, USA
| | - Katherine Bill
- Department of Internal Medicine, St. John Hospital and Medical Center, Detroit, Michigan, USA
| | - Mohammed Barawi
- Division of Gastroenterology and Interventional Endoscopy, St. John Hospital and Medical Center, Detroit, Michigan, USA
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Karagyozov P, Boeva I, Tishkov I. Role of digital single-operator cholangioscopy in the diagnosis and treatment of biliary disorders. World J Gastrointest Endosc 2019; 11:31-40. [PMID: 30705730 PMCID: PMC6354115 DOI: 10.4253/wjge.v11.i1.31] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 11/11/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023] Open
Abstract
Due to the need for improvement in the diagnosis and minimally invasive therapy of the bile duct disorders new technologies for cholangioscopy have been recently developed. Per-oral cholangioscopy has become an important diagnostic and therapeutic tool leading to avoidance of aggressive and unnecessary surgery in many clinical scenarios. This paper focuses on the newly developed SpyGlass DS technology, its advantages, and the technique of single-operator cholangioscopy (SOC), biliary indications and possible adverse events. We also review the available literature; discuss the limitations and future expectations. Digital SOC (D-SOC) is a useful technique, which provides endoscopic imaging of the biliary tree, optical diagnosis, biopsy under direct vision and therapeutic interventions. The implementations are diagnostic and therapeutic. Diagnostic indications are indeterminate biliary strictures, unclear filling defects, staging of cholangiocarcinoma, staging of ampullary tumors (extension into the common bile duct), unclear bile duct dilation, exploring cystic lesions of the biliary tree, unexplained hemobilia, posttransplant biliary complications. Therapeutic indications are lithotripsy of difficult stones, retrieval of migrated stents, foreign body removal, guide wire placement, transpapillary gallbladder drainage and endoscopic tumor ablative therapy. Most studied and established indications are the diagnosis of indeterminate biliary stricture and intraductal lithotripsy of difficult stones. The adverse events are not different and more common compared to those of Endoscopic retrograde cholangiopancreatography (ERCP) alone. D-SOC is a safe and effective procedure, adjunct to the standard ERCP and the newly available digital technology overcomes many of the limitations of the previous generations of cholangioscopes.
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Affiliation(s)
- Petko Karagyozov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
| | - Irina Boeva
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
| | - Ivan Tishkov
- Department of Interventional Gastroenterology, Clinic of Gastroenterology, Acibadem City Clinic Tokuda Hopsital, Sofia 1407, Bulgaria
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Watson RR, Parsi MA, Aslanian HR, Goodman AJ, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Sethi A, Sullivan SA, Thosani NC, Trikudanathan G, Trindade AJ, Maple JT. Biliary and pancreatic lithotripsy devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2018; 3:329-338. [PMID: 30402576 PMCID: PMC6205352 DOI: 10.1016/j.vgie.2018.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). METHODS In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. RESULTS Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. CONCLUSIONS Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.
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Key Words
- ASGE, American Society for Gastrointestinal Endoscopy
- C-APCS, Comprehensive Ambulatory Payment Classification
- CMS, Centers for Medicare and Medicaid Services
- CPT, Current Procedural Terminology (https://www.asge.org/docs/default-source/education/Technology_Reviews/doc-enteral-nutrition-access-devices.pdf?sfvrsn=4)
- EHL, electrohydraulic lithotripsy
- EPBD, endoscopic papillary balloon dilation
- ERCP, endoscopic retrograde cholangiopancreatography
- ES, endoscopic sphincterotomy
- ESWL, extracorporeal shock wave lithotripsy
- FDA, U.S. Food and Drug Administration
- FREDDY, frequency-doubled, double-pulse neodymium
- HCPCS, Healthcare Common Procedure Coding System
- MAUDE, Manufacturer and User Facility Device Experience
- ML, mechanical lithotripsy
- RCT, randomized controlled trial
- YAG, yttrium aluminum garnet
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Ayoub F, Yang D, Draganov PV. Cholangioscopy in the digital era. Transl Gastroenterol Hepatol 2018; 3:82. [PMID: 30505969 DOI: 10.21037/tgh.2018.10.08] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 10/19/2018] [Indexed: 12/16/2022] Open
Abstract
Cholangioscopy allows direct visualization and subsequent therapeutic maneuvers of the biliary ductal system. With advances in endoscopic and imaging technology, cholangioscopy has become an important modality for the diagnosis of indeterminate biliary strictures and an essential therapeutic tool for difficult to remove biliary stones. Enhanced imaging and operability of the latest generation cholangioscopes have further expanded their clinical applications to include ductal tumor ablation, gallbladder drainage, access to difficult to reach branches of the biliary tree, and biliary foreign body manipulation. In this review, we discuss the technical evolution of cholangioscopy into the digital era and review the clinical evidence supporting its use in the diagnosis and therapy of biliary tract disease.
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Affiliation(s)
- Fares Ayoub
- Department of Medicine, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dennis Yang
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida College of Medicine, Gainesville, FL, USA
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20
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Stone-Induced Purulent Choledocoduodenal Fistula Presenting with Ascending Cholangitis. ACG Case Rep J 2018; 5:e60. [PMID: 30214909 PMCID: PMC6119204 DOI: 10.14309/crj.2018.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 05/07/2018] [Indexed: 01/29/2023] Open
Abstract
A biliary enteric fistula (BEF) is a rare, abnormal communication between any segment of the biliary tree with any portion of the small or large intestine. BEF is more frequently diagnosed with the increasingly widespread use of endoscopic retrograde cholangiopancreatography. Different theories have been postulated regarding the etiology of this fistula formation, with the most likely cause being gallstones. Treatment modalities, ranging from conservative management to surgical reconstruction, show varying levels of success. We present a case of BEF secondary to large common bile duct stones, successfully treated with endoscopic sphincterotomy (EST) followed by papillary balloon dilatation, and we briefly discuss large stone retrieval in the setting of atypical anatomy.
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21
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Yang D, Buscaglia JM. Digital Single-Operator Cholangioscopy for Difficult Bile Duct Stones: Out With the Old in With the New? Clin Gastroenterol Hepatol 2018; 16:819-820. [PMID: 29199143 DOI: 10.1016/j.cgh.2017.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida
| | - Jonathan M Buscaglia
- Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York
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22
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Brown NG, Camilo J, Nordstrom E, Yen RD, Fukami N, Brauer BC, Wani S, Amateau SK, Attwell AR, Shah RJ. Advanced ERCP techniques for the extraction of complex biliary stones: a single referral center's 12-year experience. Scand J Gastroenterol 2018; 53:626-631. [PMID: 29644909 DOI: 10.1080/00365521.2018.1441434] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs. METHODS A retrospective query for AETs. PRIMARY OUTCOME Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC). RESULTS From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET's. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1-20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The 'Combination' and 'POC' groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p < .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%). CONCLUSIONS AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs.
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Affiliation(s)
- Nicholas G Brown
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Joel Camilo
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Eric Nordstrom
- b Department of Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Roy D Yen
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Norio Fukami
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Brian C Brauer
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Sachin Wani
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Stuart K Amateau
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Augustin R Attwell
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | - Raj J Shah
- a Division of Gastroenterology and Hepatology , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
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Abstract
PURPOSE OF REVIEW In 10-15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these "difficult bile duct stones." RECENT FINDINGS Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy. Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these "difficult" bile duct stones.
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Affiliation(s)
- Murad Aburajab
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Kulwinder Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, 9200, West Wisconsin Avenue, Milwaukee, WI, 53226, USA.
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24
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Franzini T, Moura RN, Bonifácio P, Luz GO, de Souza TF, dos Santos MEL, Rodela GL, Ide E, Herman P, Montagnini AL, D’Albuquerque LAC, Sakai P, de Moura EGH. Complex biliary stones management: cholangioscopy versus papillary large balloon dilation - a randomized controlled trial. Endosc Int Open 2018; 6:E131-E138. [PMID: 29399609 PMCID: PMC5794432 DOI: 10.1055/s-0043-122493] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 10/25/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % - 90 %). However, there is no study comparing these 2 techniques. PATIENTS AND METHODS From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. RESULTS The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, - 25.2 min (CI95 % - 12.48 to - 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. CONCLUSION Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.
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Affiliation(s)
- Tomazo Franzini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil,Corresponding author Tomazo Franzini, MD, PhD Av. Dr. Enéas de Carvalho Aguiar255 – Prédio dos Ambulatórios Pinheiros05403-000 Sao PauloSP – Brazil
| | - Renata Nobre Moura
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Priscilla Bonifácio
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Gustavo Oliveira Luz
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | | | - Gustavo Luis Rodela
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Edson Ide
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - Paulo Herman
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | - André Luis Montagnini
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
| | | | - Paulo Sakai
- University of Sao Paulo Medical School – Department of Gastroenterology, Sao Paulo, Brazil
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Tringali A, Cintolo M, Mutignani M. Do we really need a fully covered self-expanding metal stent for the treatment of difficult common bile duct stones? Gastrointest Endosc 2017; 86:746. [DOI: 10.1016/j.gie.2017.04.002 pmid: 28917351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2025]
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26
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Tringali A, Cintolo M, Mutignani M. Do we really need a fully covered self-expanding metal stent for the treatment of difficult common bile duct stones? Gastrointest Endosc 2017; 86:746. [PMID: 28917351 DOI: 10.1016/j.gie.2017.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 04/06/2017] [Indexed: 12/11/2022]
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Sethi A, Shah RJ. Cholangioscopy and pancreatoscopy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017. [DOI: 10.1016/j.tgie.2017.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Prospective evaluation of the short access cholangioscopy for stone clearance and evaluation of indeterminate strictures. Hepatobiliary Pancreat Dis Int 2017; 16:96-103. [PMID: 28119264 DOI: 10.1016/s1499-3872(16)60170-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peroral cholangioscopy facilitates diagnosis and therapy of biliary disorders. This study prospectively evaluated a new short access cholangioscopy. METHODS Consecutive patients were included as follows: difficult stones (group 1) underwent cholangioscopy with electrohydraulic lithotripsy and indeterminate biliary strictures (group 2) were evaluated with macroscopic assessment and cholangioscopy guided biopsy sampling. We evaluated the complete stone clearance rate (group 1) and diagnostic accuracy (group 2). Follow-up was performed over a median of 13 and 16 months, respectively. RESULTS Group 1 (n=21): complete stone clearance defined as lack of stones in cholangiography and stone removal during cholangioscopy was achieved in 15 (71.4%) patients. Clinical stone clearance defined as lack of symptoms, laboratory abnormalities and hospital visits during follow-up, irrespective of stone clearance was evident in 17 (81.0%) patients. One serious adverse event occurred (bile duct perforation). Group 2 (n=28): malignancy was confirmed in 15 patients. Sensitivity, specificity and diagnostic accuracy of cholangioscopy were 85.7%, 75.0% and 80.7%, respectively. Sensitivity, specificity and diagnostic accuracy of biopsies were 54.5%, 100.0% and 72.2%, respectively. No serious adverse events occurred, and one patient was lost to follow-up. CONCLUSIONS The novel system enabled complex stone treatment and biliary stricture diagnosis. Cholangioscopy outperformed direct biopsy regarding characterization of indeterminate strictures.
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Yang D, DiMaio CJ. Interventional endoscopy. BLUMGART'S SURGERY OF THE LIVER, BILIARY TRACT AND PANCREAS, 2-VOLUME SET 2017:511-524.e4. [DOI: 10.1016/b978-0-323-34062-5.00029-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Abstract
Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.
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Affiliation(s)
- Christopher Molvar
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
| | - Bryan Glaenzer
- Department of Radiology, Section of Vascular and Interventional Radiology, Loyola University Medical Center, Maywood, Illinois
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Komanduri S, Thosani N, Abu Dayyeh BK, Aslanian HR, Enestvedt BK, Manfredi M, Maple JT, Navaneethan U, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S. Cholangiopancreatoscopy. Gastrointest Endosc 2016; 84:209-221. [PMID: 27236413 DOI: 10.1016/j.gie.2016.03.013] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 02/08/2023]
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Mohammed N, Pinder M, Harris K, Everett SM. Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management-tertiary-centre experience and systematic review. Frontline Gastroenterol 2016; 7:176-186. [PMID: 28839855 PMCID: PMC5369546 DOI: 10.1136/flgastro-2015-100566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/08/2015] [Accepted: 05/05/2015] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Conventional endoscopic duct clearance may not be possible in up to 10%-15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6-12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable. METHODS AND AIMS A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents. RESULTS During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12 months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively. CONCLUSIONS Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12 months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.
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Affiliation(s)
- Noor Mohammed
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK,Leeds institute of Biomedical and Clinical Sciences, St James's University Hospital, University of Leeds, Leeds, UK
| | - Matthew Pinder
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Keith Harris
- Department of Radiology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Simon M Everett
- Department of Gastroenterology, Centre of digestive diseases, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Korrapati P, Ciolino J, Wani S, Shah J, Watson R, Muthusamy VR, Klapman J, Komanduri S. The efficacy of peroral cholangioscopy for difficult bile duct stones and indeterminate strictures: a systematic review and meta-analysis. Endosc Int Open 2016; 4:E263-75. [PMID: 27004242 PMCID: PMC4798839 DOI: 10.1055/s-0042-100194] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC. PATIENTS AND METHODS Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger's test. RESULTS A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % - 91 %). The accuracy of POC was 89 % (95 %CI 84 % - 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % - 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % - 9 %). CONCLUSIONS POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.
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Affiliation(s)
- Praneet Korrapati
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
| | - Jody Ciolino
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA
| | - Sachin Wani
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Janak Shah
- Division of Gastroenterology, California Pacific Medical Center, San Francisco, California, USA
| | - Rabindra Watson
- UCLA Division of Digestive Diseases, Los Angeles, California, USA
| | | | - Jason Klapman
- Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida, USA
| | - Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago Illinois, USA,Corresponding author Srinadh Komanduri, MD MS Division of Gastroenterology and HepatologyNorthwestern UniversityFeinberg School of Medicine676 St. Clair St., Suite 14-003Chicago, IL 60611USA+1-312-926-0239
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Disci E, Atamanalp SS, Ozogul B, Yildirgan MI. The Role of Choledochoscopy in Hepatopancreatobiliary Diseases. Eurasian J Med 2016; 48:29-32. [PMID: 27026761 PMCID: PMC4792493 DOI: 10.5152/eurasianjmed.2015.15299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/24/2015] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Advances in choledochoscopy technology lead to an improvement in the diagnosis and treatment of hepatopancreatobiliary diseases. The aim of this study is to reveal the role of choledochoscopy in hepatopancreatobiliary pathologies. MATERIALS AND METHODS Choledochoscopy was used under general anesthesia in operation rooms. Flexible choledochoscope inserted via a vertical choledochotomy line, which was closed by primary closure, T-tube application, or choledochoduodenal anastomosis. Olympus CHF T 20 flexible choledochoscope and related endoscopic instruments were used for the procedures. The records were evaluated retrospectively. RESULTS This study presents the findings of 235 intraoperative choledochoscopy procedures. The most common indications were suspected common bile duct stone in 96 patients (40.9%), serum cholestatic enzyme increase without jaundice in 52 (22.1%), obstructive jaundice and/or serum bilirubin increase in 46 (19.6%), and presence of dilated choledoch in 42 (17.9%). Additional endoscopic diagnostic and/or therapeutic procedures were performed 156 times in 125 patients (53.2%), and endoscopic biliary stone removal was the most used procedure (87 patients, 37.0%). The mean choledochoscopy duration was 8.5 minutes (range: 5-25 minutes). Choledochoscopy confirmed preliminary diagnosis in 117 patients (49.8%), while different data were elicited in 68 (28.9%), and normal findings were found in 50 (21.3%). In this series, no choledochoscopy-related mortality was seen, and some complications occurred in 4 patients (1.7%). CONCLUSION Intraoperative flexible choledochoscopy is a proper technique in the diagnosis and treatment of hepatopancreatobiliary disorders.
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Affiliation(s)
- Esra Disci
- Department of General Surgery, Atatürk University School of Medicine, Erzurum, Turkey
| | | | - Bunyami Ozogul
- Department of General Surgery, Atatürk University School of Medicine, Erzurum, Turkey
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YÜKSEL M, DİŞİBEYAZ S, KAPLAN M, PARLAK E, YILDIZ H, ATES İ, KAYAÇETİN E. Biliary stenting in difficult common bile duct stones: a single tertiary center experience. Turk J Med Sci 2016; 46:1779-1785. [DOI: 10.3906/sag-1602-149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 03/20/2016] [Indexed: 11/03/2022] Open
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Abstract
Cholangioscopy was first performed in the 1970s. We now use the term cholangiopancreatoscopy (CP) to reflect the wider application of these miniature reusable dual-operator "mother-daughter" endoscope systems and now fully disposable and digital single-operator optical catheters for evaluating the biliary or pancreatic duct. Cholangioscopy is an established modality for the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Pancreatoscopy is increasingly being performed to treat difficult pancreatic duct stones and may be used to distinguish malignant from benign ductal pathology. This review covers available CP technologies, indications, technique, efficacy, and complications.
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37
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Easler JJ, Sherman S. Endoscopic Retrograde Cholangiopancreatography for the Management of Common Bile Duct Stones and Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2015; 25:657-75. [PMID: 26431596 DOI: 10.1016/j.giec.2015.06.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Biliary disease is a common cause of acute pancreatitis. Risk stratification for persistent pancreatobiliary obstruction is important for selecting a treatment approach. Most common bile duct stones are extracted with standard endoscopic techniques. However, prior foregut surgery, stones with extreme morphologic attributes, and at difficult positions within the biliary system are technically challenging and predict a need for advanced biliary endoscopic techniques. Surgical common bile duct exploration at the time of cholecystectomy is appropriate in centers with experience. We outline the options and approach for the clinician to successfully identify and manage patients with symptomatic choledocholithiasis with or without biliary pancreatitis.
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Affiliation(s)
- Jeffrey J Easler
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Stuart Sherman
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA
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Abstract
Background Acute bacterial cholangitis for the most part owing to common bile duct stones is common in gastroenterology practice and represents a potentially life-threatening condition often characterized by fever, abdominal pain, and jaundice (Charcot's triad) as well as confusion and septic shock (Reynolds' pentad). Methods This review is based on a systematic literature review in PubMed with the search items ‘cholangitis’, ‘choledocholithiasis’, ‘gallstone disease’, ‘biliary infection’, and ‘biliary sepsis’. Results Although most patients respond to empiric broad-spectrum antibiotic treatment, timely endoscopic biliary drainage depending on the severity of the disease is required to eliminate the underlying obstruction. Specific recommendations have been derived from the Tokyo guideline working group consensus 2006 and its update in 2013, albeit poorly evidence-based, providing a comprehensive overview of diagnosis, classification, risk stratification, and treatment algorithms in acute bacterial cholangitis. Conclusion Prompt clinical recognition and accurate diagnostic workup including adequate laboratory assessment and (aetiology-oriented) imaging are critical steps in the management of cholangitis. Treatment is directed at the two major interrelated pathophysiologic components, i.e. bacterial infection (immediate antimicrobial therapy) and bile duct obstruction (biliary drainage). As for the latter, transpapillary endoscopic drainage by stent or nasobiliary drain and/or same-session bile duct clearance, depending on individual disease severity, represent first-line treatment approaches.
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Affiliation(s)
- Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
| | - Frank Lammert
- Department of Medicine II, Saarland University Medical Center, Homburg/Saar, Germany
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Chathadi KV, Chandrasekhara V, Acosta RD, Decker GA, Early DS, Eloubeidi MA, Evans JA, Faulx AL, Fanelli RD, Fisher DA, Foley K, Fonkalsrud L, Hwang JH, Jue TL, Khashab MA, Lightdale JR, Muthusamy VR, Pasha SF, Saltzman JR, Sharaf R, Shaukat A, Shergill AK, Wang A, Cash BD, DeWitt JM. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc 2015; 81:795-803. [PMID: 25665931 DOI: 10.1016/j.gie.2014.11.019] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 11/17/2014] [Indexed: 12/29/2022]
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40
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Abstract
Since its introduction, cholangioscopy has been used diagnostically and therapeutically. The working channel size has increased, permitting direct visualization for tissue sampling and to guide application of lithotripsy for difficult stones. Cholangioscopy utilizes endoscope and catheter-based systems. The application of slim gastroscopes for direct cholangioscopy provides better image resolution than conventional systems. Cholangioscopy has proven effective in the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Commercially available cholangioscopes are fiberoptic; those with digital video technology remain in a prototype development phase. This review covers available cholangioscope technologies, indications, technique, efficacy, and complications.
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Affiliation(s)
- Brian C Brauer
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Mailstop F-735, Room 2.031, Aurora, CO 80045, USA.
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Mailstop F-735, Room 2.031, Aurora, CO 80045, USA
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41
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Young Bang J, Coté GA. Rare and underappreciated complications of endoscopic retrograde cholangiopancreatography. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2014. [DOI: 10.1016/j.tgie.2014.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sninsky BC, Sehgal PD, Hinshaw JL, McDermott JC, Nakada SY. Expanding Endourology for Biliary Stone Disease: The Efficacy of Intracorporeal Lithotripsy on Refractory Biliary Calculi. J Endourol 2014; 28:877-80. [DOI: 10.1089/end.2014.0083] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Brian C. Sninsky
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Priyanka D Sehgal
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - J. Louis Hinshaw
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - John C. McDermott
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Stephen Y. Nakada
- Department of Urology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Mwengela D, Buxbaum J. Dilation-assisted stone extraction: does one balloon fit all? Dig Dis Sci 2014; 59:708-9. [PMID: 24414477 DOI: 10.1007/s10620-013-2989-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Accepted: 12/05/2013] [Indexed: 12/09/2022]
Affiliation(s)
- Didi Mwengela
- Division of Gastrointestinal and Liver Diseases, Hoffman Medical Research Center, Keck School of Medicine, University of Southern California, 2001 Zonal Avenue HMR 1201, Los Angeles, CA, 90033, USA
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Lenze F, Heinzow HS, Herrmann E, Berssenbrügge C, Rothenbächer H, Ullerich H, Floer M, Domschke W, Domagk D, Meister T. Clearance of refractory bile duct stones with Extracorporeal Shockwave Lithotripsy: higher failure rate in obese patients. Scand J Gastroenterol 2014; 49:209-14. [PMID: 24256056 DOI: 10.3109/00365521.2013.858767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Bile duct stones that cannot be removed endoscopically are still a challenge in interventional gastroenterology. Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option if other endoscopic means are not successful. Our study aimed to investigate the efficacy and safety of ESWL for clearance of refractory bile duct stones. MATERIAL AND METHODS A total of 73 consecutive patients treated for refractory choledocholithiasis with ESWL were retrospectively analyzed. Success and complication rates were calculated. RESULTS Complete stone clearance was achieved in 66 cases (90%). Patients with complete clearance had a significantly lower body mass index or BMI (25.55 ± 5.01 kg/m² vs. 31.60 ± 6.26 kg/m², p = 0.035) and needed less ESWL treatments (3.61 ± 1.87 vs. 5.00 ± 1.63, p = 0.048). A relevant drop of hemoglobin occurred significantly more often in the group with partial clearance (43% vs. 6%, p = 0.005). CONCLUSIONS ESWL proves to be an excellent clearing approach to refractory bile duct stones with high success rates. However, obesity is one risk factor for ESWL failure and higher procedural hazard.
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Affiliation(s)
- Frank Lenze
- Department of Medicine B, University Hospital Münster , Münster , Germany
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Aljebreen AM, Alharbi OR, Azzam N, Almadi MA. Efficacy of spyglass-guided electrohydraulic lithotripsy in difficult bile duct stones. Saudi J Gastroenterol 2014; 20:366-70. [PMID: 25434318 PMCID: PMC4271012 DOI: 10.4103/1319-3767.145329] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS We aimed to evaluate the efficacy and safety of Spyglass-guided electrohydraulic lithotripsy (EHL) for difficult common bile duct stones (CBD) not amenable to conventional endoscopic therapy. DESIGN A retrospective study evaluating the efficacy of Spyglass-guided EHL in treating difficult CBD stones, in a single tertiary care center. PATIENTS AND METHODS All patients who underwent Spyglass-guided EHL from 2012 to 2013 were compared with a historical cohort who had ECSWL. RESULTS A total number of 13 patients underwent Spyglass-guided EHL, 8 (61.5%) of them were males. The mean age was 46.5 ± 5.6 years. Bile duct clearance was achieved in 13 (100%) of them. Seventy-six percent required only one Endoscopic Retrograde Cholangiopancreatography (ERCP) to clear the CBD, 7.7% required two ERCPs, and 15.4% required three ERCPs. Adverse effects (cholangitis) occurred in one patient (10%), whereas only 30 patients (64.4%) of the ESWL group had complete CBD stone clearance. Thirty-seven percent required one ERCP to clear the CBD, 35.6% required two ERCPs, and 20% required three ERCPs. Adverse effects happened in seven (15.5%) patients, where five (11%) had cholangitis and two (4.4%) had pancreatitis. CONCLUSION Although a retrospective design with a small sample size, we concluded that Spyglass-guided EHL is an effective procedure in treating difficult CBD stones.
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Affiliation(s)
- Abdulrahman M. Aljebreen
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Address for correspondence: Dr. Abdulrahman M. Aljebreen, Department of Internal Medicine, PO Box 2925, King Khalid University Hospital, Riyadh, 11461, Saudi Arabia. E-mail:
| | - Othman R. Alharbi
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Nahla Azzam
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Majid A. Almadi
- Gastroenterology Division, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia,Gastroenterology Division, The McGill University Health Center, Montreal General Hospital, McGill University, Montreal, Canada
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Kim MJ, Cha SW, Cho YD. [Refractory bile duct stones occurring at hepaticoduodenostomy site]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2013; 62:182-4. [PMID: 24199287 DOI: 10.4166/kjg.2013.62.3.182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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de C Ferreira LEVV, Baron TH. Acute biliary conditions. Best Pract Res Clin Gastroenterol 2013; 27:745-56. [PMID: 24160931 DOI: 10.1016/j.bpg.2013.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/05/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Acute biliary complications may result from several medical conditions such as gallstone pancreatitis, acute cholangitis, acute cholecystitis, bile leak, liver abscess and hepatic trauma. Gallstones are the most common cause of acute pancreatitis. About 25% of theses patients will develop clinically severe acute pancreatitis, usually due to necrotizing pancreatitis. Choledocholithiasis, malignant and benign biliary strictures, and stent dysfunction may cause partial or complete obstruction and infection in the biliary tract with acute cholangitis. Bile leaks are most commonly associated with hepatobiliary surgeries or invasive procedures such as open or laparoscopic cholecystectomy, hepatic resection, hepatic transplantation, liver biopsy, and percutaneous transhepatic cholangiography. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) may have an essential role in the management of these complications.
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Affiliation(s)
- Lincoln E V V de C Ferreira
- Department of Medicine, Digestive Endoscopy Unit, Hospital Universitario da Universidade Federal de Juiz de Fora, Brazil
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48
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Abstract
PURPOSE OF REVIEW Endoscopists have long awaited advances in the equipment and techniques for cholangiopancreatoscopy. Since the turn of the millennium, endoscopists have witnessed an explosion in the development and refinement of the capabilities of cholangioscopes as they move from being almost exclusive to tertiary care academic settings to a wider range of practices. RECENT FINDINGS Studies have tested and constructively critiqued the procedure, hoping to increase the success rate of diagnostic and therapeutic interventions. Many have found significant improvement upon the limitations of radiographic imaging in diagnosing diseases and achieving full clearance of biliary stones. Image quality has improved with a range of features. However, most of these still need to be studied further. The addition of balloon catheters and overtubes has improved stability and access to the biliary ducts, but comes with complications that need to be studied further. SUMMARY Although we still have improvements to yearn for, the future looks bright. As endoscopists continue their commitment to the promise of direct visualization of the biliary trees and the complementary tools for diagnosis and treatment, we are continuing to raise quality of care for patients with complicated biliary diseases.
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49
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Krishnan A, Ramakrishnan R. Endoscopic Management and Role of Interim Plastic
Biliary Stenting in Large and Multiple Pigmented
Common Bile Duct Stone. Euroasian J Hepatogastroenterol 2013; 3:89-93. [DOI: 10.5005/jp-journals-10018-1072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25:376-85. [PMID: 23650878 DOI: 10.1111/den.12118] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/21/2013] [Indexed: 12/12/2022]
Abstract
Endoscopic treatment is now recognized worldwide as the first-line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system - the SpyGlass direct visualization system - are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.
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Affiliation(s)
- Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
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