Surgical therapy that alters the biliary anatomy makes endoscopic access to the biliary system difficult. These surgeries promote cholestasis, calculi development and lead to biliary stricture. Stricture resolution and removal of intrahepatic bile duct stones remain challenging.

This was a retrospective analysis of prospective data from patients with altered surgical anatomy with intrahepatic bile duct stones/strictures. Percutaneous transhepatic biliary drainage (PTBD) was attempted, followed by transhepatic SpyGlass cholangioscopy for stricture or removal of intrahepatic bile duct stones. The number of sessions, stricture dilatation, and complications were noted. A cholangiogram revealing a clear duct was a technical success, and stricture resolution was considered a clinical success. Complete ductal clearance was clinical success in those with stones. Patients with follow-up of a minimum of 6 months were included.

Twenty-four patients, 16 of whom were male (66.7%), median age 41.5 years (interquartile range [IQR] 38.2-49) successfully underwent PTBD. The most common indication was biliary stricture in 13 (54.2%), followed by intrahepatic stones in six (25%) and stones with strictures in five patients (20.8%). Most patients had undergone Roux-en-Y hepaticojejunostomy (22; 91.7%), and the level of bile duct obstruction was hilum in 20 (83.3%). The median (IQR) total bilirubin levels reduced from 6.6 (5.1-8.3) to 1.8 mg/dL (1.2-2.8) after PTBD; P <0.001. The technical success was 90.9% after a median (IQR) number of two (1.7-2) SpyGlass sessions; clinical success was 88.9% after a median of three (3-4) SpyGlass sessions. Abdominal pain (8.3%) and cholangitis (12.5%) were the complications after cholangioscopy. The median (IQR) follow-up duration was 7 months (6-8).

SpyGlass cholangioscopy, although challenging, is a safe option for intrahepatic stones and strictures with excellent short-term outcomes and minimal complications.

Objectives: Although peroral cholangioscopy has improved the endoscopic treatment of difficult stones, the treatment of intrahepatic stones remains challenging. The incidence of cholangitis is high when peroral cholangioscopy is used to treat intrahepatic stones. This study aimed to investigate the efficacy and safety of endoscopic treatment with peroral cholangioscopy for intrahepatic and common bile duct stones. Methods: Patients aged ≥20 years, who underwent endoscopic treatment with peroral cholangioscopy for intrahepatic or common bile duct stones at Tottori University Hospital from January 2016 to December 2022, were retrospectively evaluated to determine the efficacy and safety of the treatment. Results: Overall, 70 patients were included in this study: 22 in the intrahepatic stone group and 48 in the common bile duct stone group. Stones were smaller (8 vs. 17.5 mm, p < 0.001) and more numerous (p = 0.016) in the intrahepatic stone group than in the common bile duct stone group. Although the common bile duct stone group exhibited a higher rate of complete stone clearance in the first session, no significant differences were observed in the final results. The intrahepatic stone group had a higher incidence of cholangitis (36% vs. 8%, p = 0.007); however, all cases were mild. Conclusions: Endoscopic treatment with peroral cholangioscopy for intrahepatic stones may be associated with a higher incidence of cholangitis than that for common bile duct stones. Since saline irrigation may contribute to the development of cholangitis, it is important to be aware of intraductal bile duct pressure when performing peroral cholangioscopy.

Intrahepatic and extrahepatic lithiasis, a condition characterized by the presence of stones in the liver and bile ducts, is a common disease in Asia, particularly in East and Southeast Asia. We report a case with laparoscopic exploration of the common bile duct using a flexible cholangioscope and modified trans-common bile duct tunnel for hepatolithiasis combined with the dilated common bile duct.

A 35-year-old male patient has had chronic epigastric and right upper quadrant pain. The common bile duct was 11 mm dilated, and hepatolithiasis was also present, according to an upper abdomen MRI. The largest stone measured between 14 and 21 mm. A modified trans-common bile duct tunnel from the abdominal wall into the common bile duct was used in a laparoscopic procedure to examine the common bile duct. Complications during the procedure or following it were not present. The procedure took 120 min, and the blood loss was about 50 ml. The patient was discharged on the sixth postoperative day, and a follow-up visit one month later revealed that single-session stone clearance had been accomplished.

Laparoscopic exploration of the common bile duct using a cholangioscope and modified trans-choledochal tube is applicable in selected patients and can be effectively and safely used to treat hepatolithiasis combined with the dilated common bile duct.

In this case, we present an innovative approach for hepatolithiasis when combined with dilated common bile duct.

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Mirizzi syndrome is a rare chronic cholecystitis complication. However, the current consensus on managing this condition remains controversial, especially through laparoscopic surgery. This report describes the feasibility of treating type I Mirizzi syndrome with laparoscopic subtotal cholecystectomy and electrohydraulic lithotripsic gallstone removal. A 53-year-old woman presented with dark urine and right upper quadrant pain for 1 month. On examination, she was jaundiced. Blood tests showed highly elevated liver and biliary enzyme levels. Abdominal ultrasound showed a slightly dilated common bile duct with suspicion of choledocholithiasis. However, endoscopic retrograde cholangiopancreatography showed a narrowed common bile duct extrinsically compressed by a gallstone in the cystic duct, establishing a Mirizzi syndrome diagnosis. Elective laparoscopic cholecystectomy was planned. At operation, the trans-infundibulum approach was used since dissection around the cystic duct was difficult due to severe local inflammation of Calot's triangle. The gallbladder's neck was opened, and the stone was removed by lithotripsy via a flexible choledochoscope. Common bile duct exploration through the cystic duct was normal. The fundus and body of the gallbladder were resected, followed by T-tube drainage and suturing of the gallbladder's neck. The patient's postoperative clinical course was uneventful. Treating Mirizzi syndrome remains a major challenge for hepatobiliary specialists even with open surgery due to high complication rates, including bile duct injuries. Treatment is primarily to clear out the responsible stone and necrotic tissue. Due to advances in endoscopic surgery and equipment, subtotal cholecystectomy with laparoscopic gallstone extraction provides a safe and effective option for patients with Mirizzi syndrome. Laparoscopic subtotal cholecystectomy with electrohydraulic lithotripsy is a feasible and useful approach for treating Mirizzi syndrome that avoids iatrogenic bile duct injury.

Endoscopic management of large bile duct stones may be challenging and refractory to standard endoscopic retrograde cholangiopancreatography (ERCP) techniques. To this end, per-oral cholangioscopy (POC)-guided electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) has been increasingly utilized during ERCP. There are limited data, however, comparing EHL and LL in the management of choledocholithiasis. Therefore, the aim was to analyze and compare the efficacy of POC-guided EHL and LL for the treatment of choledocholithiasis.

A database search on PubMed was performed selecting prospective English-language articles published by September 20th, 2022, in accordance with PRISMA guidelines. Studies selected included bile duct clearance as an outcome.

A total of 21 prospective studies (15 using LL, 4 using EHL, and 2 both) including 726 patients were included for analysis. Complete ductal clearance was achieved in 639 (88%) patients with 87 (12%) patients having incomplete ductal clearance. Patients treated with LL had an overall median stone clearance success rate of 91.0% (IQR, 82.7-95.5), whereas EHL achieved a median stone clearance success rate of 75.8% (IQR, 74.0-82.4), [p = .03].

LL is a highly effective form of POC-guided lithotripsy for the treatment of large bile duct stones, particularly when compared to EHL. However, direct, head-to-head randomized trials are needed to identify the most effective form of lithotripsy for treating refractory choledocholithiasis.

To analyze the benefits of laparoscopic common bile duct exploration and laparoscopic cholecystectomy (LCBDE + LC) versus endoscopic retrograde cholangiopancreatography and/or endoscopic sphincterotomy following laparoscopic cholecystectomy (ERCP/EST + LC) for difficult common bile duct stones combined with gallstones.

A retrospective analysis of consecutive patients with difficult common bile duct stones combined with gallstones in three hospitals from January 2016 to January 2021 was performed.

ERCP/EST + LC contributed to reducing postoperative drainage time. However, LCBDE + LC showed a higher rate of complete clearance, along with lower postoperative hospital stays, expenses and incidence of postoperative hyperamylasemia, pancreatitis, re-operation and recurrence. In addition, LCBDE + LC showed safe and feasible performance in the elderly and patients with previous upper abdominal surgery.

It is an effective and safe method for LCBDE + LC for difficult common bile duct stones combined with gallstones.

Mirizzi syndrome is a rare complication of chronic calculous cholecystitis. Preoperative diagnosis is challenging due to the absence of pathognomonic signs and symptoms and low sensitivity rates of imaging tests. Historically, laparotomy has been the preferred choice of surgical management. Endoscopic and laparoscopic approaches have been increasingly described as diagnostic and therapeutic options for Mirizzi type I and II, but data is limited regarding the management of more complex cases. We describe a staged endoscopic and laparoscopic approach for the management of type IV Mirizzi syndrome and review the management options.

The optimal treatment options for gallstones together with common bile duct stones (CBDS) remain controversial. The aim of this study was to further compare the recurrence rate of stones after synchronous laparoscopic cholecystectomy combined with laparoscopic common bile duct exploration (SLCL) and synchronous laparoscopic cholecystectomy combined with intraoperative endoscopic sphincterotomy (SLCE) and to determine which option is more effective in reducing the rate of repeated recurrence of CBDS and the incidence rate of hepatolithiasis.

We retrospectively investigated the clinical data of patients who underwent SLCL or SLCE at our hepatobiliary center between August 2012 and August 2020. The primary and secondary endpoints of this study were the recurrence of CBDS and the occurrence of hepatolithiasis, respectively.

In total, 1005 patients were enrolled in this study, including 431 patients in the SLCL group and 574 patients in the SLCE group. SLCL was associated with a significantly decreased rate of CBDS recurrence (4.18% vs. 7.84%, P = 0.018), repeated CBDS recurrence (0.70% vs. 3.00%, P = 0.010), and incidence of hepatolithiasis (0.00% vs. 1.05%, P = 0.040). Compared with SLCE, SLCL was an independent protective predictor of the recurrence of CBDS (relative risk, 0.505; 95% confidence interval, 0.286-0.891; P = 0.018) and repeated recurrence of CBDS (relative risk, 0.226; 95% confidence interval, 0.066-0.777; P = 0.018).

SLCL is an optimal treatment option to SLCE for patients with gallstones combined with CBDS.

A peroral cholangioscope (POCS) can allow direct visualization of the biliary mucosa and its use is becoming more widespread due to improvements in functionality, image quality, and operability, as well as the development of related devices. Recently, a novel mother-baby peroral cholangioscope (nMB-POCS) with a large (2-mm) accessory channel has been developed. In this study, we evaluated the feasibility of this novel POCS in a dry simulation and animal model.

We evaluated the ease of insertion and maneuverability of the nMB-POCS, the image quality, and the passage of the devices into the accessory channel and into the common bile duct in a dry and live porcine model.

In both models, the nMB-POCS could be easily inserted into the duodenoscope and into the distal bile duct and hilum. The image quality was good, and it was possible to observe the surface structure and the vascular network of the bile duct mucosa in detail.

The nMB-POCS with its larger accessory channel is expected to improve the efficiency of diagnosis and  treatment, and reduce the procedure time. Clinical studies in patients are warranted.

Endoscopic retrograde cholangiopancreatography (ERCP) is the technique of choice for the treatment of biliopancreatic pathology. However, fluoroscopic imaging does not always allow an adequate diagnosis. On the other hand, some large stones cannot be removed by the usual methods. In these situations, cholangioscopy has proven to be an essential tool for the diagnosis of biliary strictures and the treatment of large stones. Its role in pancreatic pathology is also increasing. The development of a single-operator, disposable cholangioscope has made it possible to expand the technique to a large number of hospitals that perform ERCP. For this reason, the Spanish Society of Digestive Endoscopy has developed this consensus document on the use of the Spyglass-DS cholangioscope. The document has been prepared by a group of endoscopists with expertise in cholangioscopy, reviewing the scientific evidence on the main current indications for cholangiopancreatoscopy.

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound-guided antegrade intervention (EUS-AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS-AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS-AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy.

A 76-year-old man presented with liver dysfunction and intrahepatic bile duct dilatation. Imaging studies showed two large stones that had become impacted in the common hepatic duct, which was fused with the gallbladder. The patient was diagnosed with Mirizzi syndrome type IV. Hepaticojejunostomy and stone removal failed due to dense gallbladder adhesions involving the right hepatic artery. The bile flow was temporarily restored; however, the patient experienced cholangitis 16 months later. The stones were extracted via peroral single-operator cholangioscopy (SOC)-guided electrohydraulic lithotripsy. This is the first case in which stones were completely removed by SOC-guided treatment in a patient with Mirizzi syndrome type IV.

This study aimed to evaluate the efficacy and safety of stone extraction in patients who underwent Roux-en-Y gastrectomy using short-type single-balloon enteroscopy (SBE) and to clarify the factors affecting complete stone extraction in the initial procedure.

The data of patients with Roux-en-Y gastrectomy who underwent endoscopic stone extraction using short SBE between September 2011 and January 2022 was analyzed.

Overall, 85 patients were scheduled to undergo stone extraction. 77 patients were intended stone extraction after successful biliary cannulation. The complete stone extraction success in the initial procedure, overall complete stone extraction success including repeated procedures, and adverse event rates were 68.2% (95% confidence interval [CI], 57.2%-77.9%), 87.1% (95% CI, 78.0%-93.4%), and 8.2% (95% CI, 3.4%-16.2%), respectively. Multiple logistic regression analysis indicated that bile duct diameter affected the success of complete stone extraction after successful biliary cannulation in the initial procedure (odds ratio 0.53, 95% CI, 0.30-0.94, p = .03).

Stone extraction in patients with Roux-en-Y gastrectomy using short SBE was effective. Patients with a large diameter bile duct required several sessions for complete stone extraction, suggesting that more dedicated devices are warranted for patients with surgically altered anatomy.

BACKGROUND : Endoscopic stone extraction is often challenging in patients with a significant lower bile duct corner pocket, where small stones are likely to escape and become impacted. This study aimed to determine the utility of different types of baskets for retrieving corner pocket stones. METHODS : Seven types of retrieval baskets were evaluated on silicone models. The study outcomes included the characteristics of each basket and technical success rates associated with the retrieval of stones impacted in the corner pocket. RESULTS : The overall success rate was only 27.5 %, with significant differences between the baskets (P < 0.001). Only three baskets yielded successful removal. The success rates were 10 %, 25 %, and 70 % with the 8-wire Nitinol Basket, RASEN, and VorticCatch V, respectively, all of which are helical eight-wire baskets. RASEN and VorticCatch V share similar characteristics, including a strong spiral wire and smaller interwire spaces at their distal ends. The addition of rotation significantly increased the success rate to 80 % with the 8-wire Nitinol Basket (P < 0.001) and 90 % with RASEN (P < 0.001). CONCLUSIONS : Robust helical eight-wire baskets with smaller interwire spaces at the tip may be effective for extracting corner pocket stones, while the addition of rotational motion may improve the efficacy of retrieval.

Background and study aims  Single-operator peroral cholangioscopy (SOC) is a therapeutic modality for difficult biliary stone disease. Given its high success rate and increasing availability, analysis of the economic impact of early SOC utilization is critical for clinical decision-making. Our aim is to compare the cost-effectiveness of different first and second-line endoscopic modalities for difficult-to-treat choledocholithiasis. Patients and methods  A decision-tree model with a 1-year time horizon and a hypothetical cohort of 200 patients was used to analyze the cost-effectiveness of SOC for first, second and third-line intervention in presumed difficult biliary stones. We adopted the perspective of a Canadian tertiary hospital, omitting recurrence rates associated with endoscopic retrograde cholangiopancreatography (ERCP). Effectiveness estimates were obtained from updated meta-analyses. One-way sensitivity analyses and probabilistic sensitivity analyses were also performed to assess how changes in key parameters affected model conclusions. Results  First- and second-line SOC achieved comparable clinical efficacy from 96.3 % to 97. 6 % stone clearance. The least expensive strategy is third-line SOC (SOC-3: $800,936). Performing SOC during the second ERCP was marginally more expensive (SOC-2: $ 816,584) but 9 % more effective. The strategy of first-line SOC incurred the highest hospital expenditures (SOC-1: $ 851,457) but decreased total procedures performed by 16.9 % when compared with SOC-2. Sensitivity analysis was robust in showing SOC-2 as the most optimal approach. Conclusions  Second-line SOC was superior to first and third-line SOC for treatment of difficult biliary stones. When based on meta-analysis of non-heterogeneous trials, SOC-2 is more cost-effective and cost-efficient. Our study warrants a larger pragmatic effectiveness trial.

Peroral cholangioscopy (POC)-guided lithotripsy is an effective treatment for difficult biliary stones. A clear definition of factors associated with the efficacy of POC-guided lithotripsy in one session and the performance of electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL) have not clearly emerged.

This was a non-randomized prospective multicenter study of all consecutive patients who underwent POC lithotripsy (using EHL and/or LL) for difficult biliary stones. The primary endpoint of the study was the number of sessions needed to achieve complete ductal clearance and the factors associated with this outcome. Secondary endpoints included the evaluated efficacies of LL and EHL.

Ninety-four patients underwent 113 procedures of EHL or LL. Complete ductal clearance was obtained in 93/94 patients (98.94%). In total, 80/94 patients (85.11%) achieved stone clearance in a single session. In the multivariate analysis, stone size was independently associated with the need for multiple sessions to achieve complete ductal clearance (odds ratio = 1.146, 95% confidence interval: 1.055-1.244; p = 0.001). Using ROC curves and the Youden index, 22 mm was found to be the optimal cutoff for stone size (95% confidence interval: 15.71-28.28; p < 0.001). The majority of the patients (62.8%) underwent LL in the first session. Six patients failed the first session with EHL after using two probes and therefore were crossed over to LL, obtaining ductal clearance in a single additional session with a single LL fiber. EHL was significantly associated with a larger number of probes (2.0 vs. 1.02) to achieve ductal clearance (p < 0.01). The mean procedural time was significantly longer for EHL than for LL [72.1 (SD 16.3 min) versus 51.1 (SD 10.5 min)] (p < 0.01).

POC is highly effective for difficult biliary stones. Most patients achieved complete ductal clearance in one session, which was significantly more likely for stones < 22 mm. EHL was significantly associated with the need for more probes and a longer procedural time to achieve ductal clearance.

Complex biliary stones may be challenging to remove with standard endoscopic techniques. Factors contributing to complexity include large stone size (≥15 mm), multiple stones, high stone:distal duct ratio, stones above strictures and those in difficult anatomic position. In these cases, additional techniques may be needed, such as endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopic visually directed lithotripsy, and extracorporeal shockwave lithotripsy. The choice of technique depends on local expertise and resources. Cases should be planned to identify the appropriate technique to avoid multiple procedures. This article describes the factors linked to difficulty and the steps to overcome them.

Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.

Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) provides an alternative method for cholelithiasis treatment. Since conventional rigid choledochoscope applied in PTCSL lacks high flexibility and high-resolution vision, we developed a new, soft fiber-optic choledochoscope (SFCS) to solve these problems.

We aim to verify the safety and efficacy of PTCSL guided by the newly developed choledochoscope, SCFS.

In this study, a total of 58 patients undergoing PTCSL from November, 2020 to December, 2020 in Zhuhai People's Hospital were enrolled, including 32 patients undergoing conventional PTCSL and 26 patients undergoing SFCS-guided PTCSL. A method of propensity score matching was used in order to balance the pre-operative indexes of the two groups. As a result, a total of 21 pairs (1:1) were created. SFCS-guided PTCSL was performed on patients in the SFCS group for the treatment of cholelithiasis. The operation time, intraoperative blood loss, immediate clearance rate, final clearance rate, postoperative hospitalization time, postoperative complication rate, and recurrence rate were compared between the two groups. A 6-month follow-up was performed for the two groups.

SFCS-guided PTCSL represents safe and effective treatment outcomes. The immediate clearance rate and final clearance rate in the SFCS group were significantly higher than that of the conventional group. Operation time, intraoperative blood loss, postoperative hospitalization days, and recurrence rate in the SFCS group were significantly lower than that of the conventional group.

SFCS applied in PTCSL appears to be a safe and effective method for the treatment of cholelithiasis. This study has been registered in Chinese Clinical Trial Registry as required by legislation (Registration number: ChiCTR1800016864, Registration time: 2018/02/08).

Mirizzi syndrome is a rare complication of gallbladder disease that can be difficult to treat. In particular, endoscopic treatment often fails because of the inability to access or to capture the impacted cystic duct stone. We report a case of Mirizzi syndrome grade III that was successfully managed by digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage and interval laparoscopic cholecystectomy. Based on our experience, digital single-operator peroral cholangioscopy-guided electrohydraulic lithotripsy with endoscopic nasogallbladder drainage is a feasible minimally invasive approach for the management of high-grade Mirizzi syndrome.

This study aimed to evaluate and compare the outcomes of palliative endoscopic biliary stenting (EBS) and complete stone removal among elderly patients with choledocholithiasis using propensity score matching.

From April 2012 to October 2017, 161 patients aged 75 years and older with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography at our institution. Among them, 136 (84.5%) had complete stone removal, and 25 (15.5%) underwent palliative EBS without further intervention until symptom occurrence. The median age of the EBS group was significantly higher than that of the complete stone removal group. The proportion of patients with dementia, cerebral infarction, preserved gallbladder with gallstones, and surgically altered anatomy was higher in the EBS group than in the complete stone removal group. Propensity score matching was used to adjust for different factors. In total, 50 matched patients (n = 25 in each group) were analyzed.

The median duration of cholangitis-free periods was significantly shorter in the EBS group (596 days) than in the complete stone removal group. About half of patients in the EBS group required retreatment and rehospitalization for cholangitis during the observation period. Cholangitis was mainly caused by stent migration. There was no significant difference in terms of mortality rate and procedure-related adverse events between the two groups. Death was commonly attributed to underlying diseases. However, one patient in the EBS group died due to severe cholangitis.

Palliative EBS should be indicated only to patients with choledocholithiasis who have a poor prognosis.

Digital single-operator cholangioscopy (dSOC) has revolutionized bile duct visualization. Interventions like electrohydraulic or laser lithotripsy, inspection of suspicious areas, and targeted biopsies have become possible quick and easy. One main indication for dSOC remains the evaluation of indeterminate biliary strictures.

We analyzed 180 consecutive dSOCs procedures performed in a high-volume tertiary center to evaluate sensitivity, specificity as well as positive and negative predictive values (PPV and NPV) for indeterminate strictures. Furthermore, technical success and complications were analyzed.

In 92-97%, the region of interest was reached and successfully visualized. In 83-100%, targeted biopsies were obtained from the suspicious area. Only the distal bile duct was less successful with only 84 and 62%, respectively. In general, dSOC procedures were safe. Cholangitis was the main complication. Regarding the diagnostic accuracy of dSOC of indeterminate biliary strictures, we found a sensitivity of 0.87 and specificity of 0.88, over all. Within the whole cohort, the investigators' assessment directly after dSOC had a PPV of 0.63 and a NPV of 0.97. In patients with biliary lesions or stenosis suspicious for malignancy, the dSOC-based visual diagnosis revealed a very high diagnostic accuracy with sensitivity and specificity of 1.0 (95% CI 0.86-1.0) and 0.76 (95% CI 0.56-0.9) with a PPV of 0.77 (95% CI 0.59-0.9) and a high NPV of 1.0 (95% CI 0.85-1.0).

Our study demonstrates that dSOC has a high diagnostic accuracy as well as a favorable safety profile. Therefore, dSOC should be discussed as standard of care during endoscopic retrograde cholangiography for indeterminate biliary lesions.

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.

Endoscopic stone removal is currently the first-line procedure for the treatment of common bile duct stones. Advances in equipment and treatment techniques have expanded the scope of application of endoscopic treatment to include stones that have previously been difficult to remove endoscopically, such as stacked stones and large stones. For the treatment of common bile duct stones in elderly patients in particular, long-term placement of a biliary stent is increasingly being selected. Although periodic stent replacement is required, some reports have stated that biliary stenting is useful in terms of treatment-associated invasiveness and the incidence of accidental complications. To date, various opinions have been presented on whether the treatment of bile duct stones should aim for complete removal of stones or adopt the biliary stenting approach. Findings in previous reports suggest that both the approach for complete stone removal and the long-term stenting approach are associated with advantages and disadvantages. In this study, we reviewed previous reports on the significance of placing a stent and implementing careful monitoring rather than stone removal in patients with bile duct stones.

Endoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5-15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones.

Consecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications.

During the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up.

LL is a highly effective and safe procedure with minimal and transient complications.

Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.

Highlight Bile duct stone extraction is sometimes difficult in patients with surgically altered anatomy. Tanisaka and colleagues present a video case report demonstrating the usefulness of a novel retrieval basket with a unique helical shape, which facilitates the extraction of difficult bile duct stones, even in patients with surgically altered anatomy.

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bileduct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Laparoscopic common bile duct exploration (LCBDE) has gained wide popularity for the treatment of choledocholithiasis. However, it remains unclear whether LCBDE is a better alternative option for the patients with difficult biliary stones. Thus, the aim of the present study was to explore the safety and efficacy of LCBDE for these patients by retrospectively analyzing our data and combing with literature review.

Between September 2011 and February 2019, 1064 consecutive patients who underwent LCBDE at Shanghai Tenth People's Hospital were reviewed. The clinical data of patients with difficult biliary stones were selected and retrospectively analyzed.

Of these patients, 334 cases were confirmed with difficult biliary stones, and the overall complete stone clearance rate was 98.8% (330/334). 34 cases (10.2%) were performed with laser lithotripsy. A total of 296 patients (88.6%) underwent primary closure of common bile duct, and T-tube drainage was indwelled in 38 patients (11.4%). No bile duct injury, bleeding, perforation and surgery-related deaths were observed. The overall morbidity rate was 6.6%. 16 cases (4.8%) occurred in bile leakage with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 9 months with stone recurrence occurring in 9 patients (2.7%). There was no evidence of bile duct stricture in all cases.

The current study suggests that LCBED is a considerable safe and effective option for the patients with difficult biliary stones. A randomized clinical trial is needed to further evaluate the benefit of LCBDE in this subgroup.

Mirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution.

We present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90-100% success rate in the treatment of biliary stones.

Herein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition.

ERCP is the standard treatment for common bile duct stones. On the other hand, 10-15% of cases involve intractable common bile duct stones, which cannot be treated by conventional biliary sphincterotomy with a stone retrieval method. Large bile duct stones are typically managed by mechanical lithotripsy and endoscopic papillary large balloon dilatation. Peroral cholangioscopy techniques can be applied if this technique fails. In the present case, a 67-year-old woman had a large common bile duct stone that could not be retracted using the conventional ERCP stone extraction method. The common bile duct stone was eventually removed by direct peroral upper gastrointestinal endoscopy and a polypectomy snare.

The evolution of advanced pancreaticobiliary endoscopy in the past 50 years is remarkable. Endoscopic retrograde cholangiopancreatography (ERCP) has progressed from a diagnostic test to an almost entirely therapeutic procedure. The endoscopist must have a clear understanding of the indications for ERCP to avoid unnecessary complications, including post-ERCP pancreatitis. Endoscopic ultrasound initially was used as a diagnostic tool but now is equipped with accessary channels allowing endoscopic ultrasound-guided interventions in various pancreaticobiliary conditions. This review discusses the endoscopic management of common pancreatic and biliary diseases along with the techniques, indications, outcomes, and complications of pancreaticobiliary endoscopy.

Objective Recently, a new digital peroral cholangioscopy (POCS) system, the SpyGlass DS (SpyDS), has been used for POCS-guided lithotripsy for difficult bile duct stones (DBDSs). The aim of this retrospective study was to compare the efficacy of SpyDS-guided electrohydraulic lithotripsy (EHL) for DBDS with that of a conventional digital cholangioscope. Methods Seventeen consecutive patients who had undergone POCS-guided EHL for DBDS with the SpyDS between October 2015 and January 2019 were enrolled in this study group (SpyDS group) using a prospectively maintained database. Fifteen other consecutive patients who had undergone POCS-guided EHL with a conventional digital cholangioscope (CHF-B260) just prior to the introduction of the SpyDS between December 2006 and September 2015 were analyzed as a control group (CHF group). The main outcome measurement was the total procedure time to complete stone removal. Results The rate of complete stone removal was 100% for both groups. The mean total procedure time for the SpyDS group was significantly shorter than that for the CHF group (67±30 minutes vs. 107±64 minutes, p=0.038). The mean number of endoscopic sessions for the SpyDS group was significantly lower than that for the CHF group (1.35±0.49 vs. 2.00±0.85, p=0.037). There were no significant differences in the rate of adverse events between the two groups. Conclusion The SpyDS appears useful for decreasing the procedure time and number of endoscopic sessions for complete stone removal in POCS-guided EHL for DBDS compared with a conventional digital cholangioscope.

Background: Balloon-assisted stone extraction (BASE) can be applied to remove the common bile duct (CBD) stones during laparoscopic CBD exploration (LCBDE). This study aimed to analyze the efficacy of BASE. Methods: A retrospective analysis of patients with CBD stone who underwent LCBDE using BASE from 2001 to 2017 was conducted. The outcomes of BASE and potential factor for failure of technique were also evaluated. Results: A total of 163 patients underwent LCBDE using BASE were enrolled. Success rate of BASE was 88.3% (144/163) and 19 (11.7%) patients with failed BASE underwent basket for lithotripsy additionally. The reason for aborting BASE were stone impaction (n = 6), small stone (n = 4), migration into intrahepatic duct (IHD) (n = 3), and others (n = 6). The overall success rate of stone clearance was 98.2% (160/163). The mean CBD diameter was 15.8 mm (range 7-34 mm), and the largest stone size was 13.8 mm (range 3-36 mm). The overall rate of complication related with procedure was 4.9% (8/163), including bile leakage in 2 patients (1.2%), bleeding in 2 patients (1.2%), and pancreatitis in 4 patients (2.4%). There was no procedure-related mortality. Conclusions: BASE for CBD stone is safe and effective technique for the treatment of CBD stones.

Since its inception in 2007, single-operator cholangioscopy (SOC) has gained popularity for many diagnostically and therapeutically challenging biliary and pancreatic conditions. Many studies have been published to evaluate the feasibility, usefulness, cost-effectiveness, and safety profile of the first generation. This paper is a descriptive study in which we aim to share the experience of two tertiary care centers with the novel version of SOC, SpyGlass DS.

We retrospectively reviewed the records of all the patients who went through the procedure from October 2015 - July 2019 to explore the scope of biliary and pancreatic conditions in which SOC was utilized. Technical success was defined as the ability to visualize the lesion and complete the procedure as planned, whereas clinical success was determined by the ability to achieve the desired diagnostic/therapeutic outcome.

During the period of interest, 66 patients (34 males) went through 84 cholangioscopy procedures. Forty-four patients failed the conventional extraction methods and needed the intervention for the treatment of difficult stones, 24 patients needed a diagnostic evaluation of biliary strictures, and 3 needed an intervention to remove migrated stents. Technical success was achieved in 98.8% (83/84) of the procedures (95% CI: 96-100%). Regarding clinical success, stone breakdown and removal was achieved in 92% of the procedures (49/53; 95% CI: 85-100%). Tissue samples were successfully obtained in 95.8% (23/24) of patients with strictures (95% CI: 88-100%). The biopsy was appropriate to make a histological diagnosis in 83.3% of cases (20/24; 95% CI: 68-98%). The median number of sessions needed to achieve the deisred outcome was one (ranging between 1 and 6 sessions).

The new version of SOC, SpyGlass DS, provides a feasible and an effective option for the management of difficult cholelithiasis, as well as visually evaluating and obtaining histological samples for indeterminate biliary strictures. However, data from more extensive studies are needed to establish its non-inferiority to the fiberoptic version in terms of short- and long-term outcomes, cost-effectiveness, and complications.

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.

Bile duct stones, indeterminate biliary strictures and other biliary duct pathologies represent a significant surgical and endoscopic challenge in patients with altered luminal or biliary anatomy. Traditional endoscopic retrograde cholangiopancreatography (ERCP) is not feasible and alternative approach is usually required. A novel alternative approach of addressing these challenging cases is assessed by this case series. All patients who underwent percutaneous transhepatic cholangioscopy (PTCS) and Spyglass^TM Direct visualization system (SDVS) between December 2016 and February 2018 were studied. The indications for procedure, interventions performed, outcomes and complications were reviewed for each case. Spyglass^TM marketed by Boston Scientific Corporation, Marlborough, Massachusetts was utilized by interventional endoscopists and radiologists through a 12 French (Fr) percutaneous vascular sheath. Five patients had altered biliary and/or luminal anatomy: two with Roux-en-Y gastric bypass and three with Roux-en-Y hepaticojejunostomy. All patients had unsuccessful previous ERCP attempts. All PTCS with SDVS procedures were technically successful. Indications for this unusual approach were: ascending cholangitis, abnormal liver function tests and biliary dilation on imaging. SDVS was utilized to conduct electrohydraulic lithotripsy (EHL) for biliary stone management in four patients and intraductal biopsies for indeterminate strictures in two of them. PTCS with SDVS can be beneficial for multiple diagnostic and therapeutic indications in patients with altered biliary or luminal anatomy. SDVS allows direct evaluation and management of different biliary pathologies in challenging cases where traditional ERCP is not feasible. Some indications for PTCS with SDVS include evaluation of biliary strictures and biliary stasis, biliary tract biopsy and lithotripsy for management of biliary stones.