Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones

Usefulness of percutaneous transhepatic cholangioscopic lithotomy for removal of difficult common bile duct stones

Background/Aims

Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones.

Methods

This study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL.

Results

Among 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality.

Conclusions

Despite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Safety and efficacy of laser lithotripsy for complicated biliary stones using direct choledochoscopy

BACKGROUND

The first-line therapy for choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction, which is successful in over 90% of cases. However, large biliary stones often require extracorporeal shockwave lithotripsy, electrohydraulic lithotripsy (EHL), or laser lithotripsy. The objective of our study was to assess the safety and efficacy of laser lithotripsy with choledochoscopy guidance.

METHODS

Between March 2001 and November 2009, laser lithotripsy with a holmium laser was used for complicated bile stones in 20 patients. All patients included had failed standard stone extraction techniques after a mean of 2.1 ± 1.1 ERCP sessions. Main outcome measures included complete stone clearance and complications post-procedure.

RESULTS

Twenty patients (mean age 61.0 ± 22.3 years, six men) underwent laser lithotripsy with a mean stone size was 2.2 cm (range 1.1-3.5 cm) and a mean number of stones of 2.2 (range 1-6). A mean of 0.25 ± 0.20 kJ was applied during laser lithotripsy sessions with a mean procedure time of 85.3 ± 23.0 min. The majority (18/20, 90%) achieved final clearance after a mean of 1.4 ± 0.8 (29 total) laser sessions and a mean of 1.9 ± 0.8 (38 total) ERCP sessions. Five complications occurred: two patients required post-procedure admission for pain and three patients had bile leaks. All bile leaks were minor and resolved after biliary stenting.

CONCLUSIONS

Laser lithotripsy using the holmium laser is safe and effective with direct cholangioscopic guidance. Further prospective studies are warranted.

Clinical utility of single-operator cholangiopancreatoscopy using a SpyGlass probe through an endoscopic retrograde cholangiopancreatography catheter

BACKGROUND AND AIM

A single-operator cholangiopancreatoscopy was developed to overcome a problem in conventional peroral cholangiopancreatoscopy. The aim of this pilot study was to clarify the clinical utility of single-operator cholangiopancreatoscopy using a SpyGlass probe through an endoscopic retrograde cholangiopancreatography (ERCP) catheter.

METHODS

Patients undergoing ERCP with a SpyGlass probe passed through a catheter were included in this study. The SpyGlass probe was inserted into the catheter following successful cannulation, and cholangiopancreatoscopy was performed by a single operator. We retrospectively analyzed the successful visualization rate of this technique.

RESULTS

Fifteen patients were included in this study. SpyGlass cholangiopancreatoscopy was technically successful in all patients. Successful visualization was obtained in nine patients (60%). The median SpyGlass procedure time was 10 min. Cholangiopancreatoscopic diagnoses were as follows: bile duct carcinoma in three patients; intraductal papillary mucinous adenoma in two; and intraductal pancreatic stone, benign biliary stricture, gallbladder cholesterolosis, and gallbladder carcinoma in one each. There were no cases of post-ERCP pancreatitis.

CONCLUSIONS

While the low rate of successful visualization must be improved, single-operator cholangiopancreatoscopy using a SpyGlass probe through an ERCP catheter is a safe and effective procedure.

Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts

Stones in biliary and pancreatic ducts are entities that plague hundreds of thousands of patients worldwide every year. Symptoms can be mild (pain) to life threatening (cholangitis, severe acute pancreatitis). In the last few decades, management of these stones has transitioned from exclusively surgical to now predominantly endoscopic techniques. This article reviews the evolution of endoscopic techniques used in the management of stones in the common bile duct and pancreatic duct.

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis, a plethora of endoscopic techniques and devices appeared in order to facilitate rapid, safe and effective bile duct stones extraction. Nowadays, endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients. Large common bile duct stones are treated conventionally with mechanical lithotripsy, while the most serious complication of the procedure is “basket and stone impaction” that is predominately resolved surgically. In cases of difficult, impacted, multiple or intrahepatic stones, more sophisticated procedures have been used. Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems, ultra-thin cholangioscopes, thin endoscopes and ultimately using the novel single use, single operator SpyGlass Direct Visualization System, in order to deliver intracorporeal shock wave energy to fragment the targeted stone, with very good outcomes. Recently, large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials. When compared with mechanical lithotripsy or with balloon dilation alone, it proved to be superior. Moreover, dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic. Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of “impaction” because it seems that is an effective, inexpensive, less traumatic, safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists. When complete extraction of large stones is unsuccessful, the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy. Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective. The great majority of patients with large stones can be treated endoscopically. In cases of unsuccessful stone extraction using balloons, baskets, mechanical lithotripsy, electrohydraulic or laser lithotripsy and large balloon dilation, the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.

Identification of cholangiocarcinoma by using the Spyglass Spyscope system for peroral cholangioscopy and biopsy collection

BACKGROUND & AIMS

It is a challenge to collect samples from bile duct strictures to diagnose patients with cholangiocarcinoma. We investigated the utility of the Spyglass Spyscope, a single-operator endoscope that is used to perform cholangiopancreatoscopy, to identify extrahepatic cholangiocarcinoma in patients who were not diagnosed with this disorder by endoscopic retrograde cholangiopancreatography (ERCP) cytology or endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) analyses.

METHODS

We conducted a retrospective analysis of data from 30 patients (median age, 67 years; 67% male) with indeterminate extrahepatic biliary strictures who were ultimately diagnosed with cholangiocarcinoma but had inconclusive results from initial biliary ductal brush cytology and EUS-FNA analyses. Patients then underwent cholangioscopy by using the Spyglass Spyscope and intraductal biopsy analysis. None of the patients had a definitive mass in abdominal imaging or EUS analyses.

RESULTS

The biliary stricture was located in the common bile duct in 13 patients and in the common hepatic duct in 17 patients. The Spyglass Spyscope system had 77% accuracy (23 of 30) in the diagnosis of malignancies that were inconclusive on the basis of ERCP-guided brush or EUS-FNA analyses.

CONCLUSIONS

The Spyglass Spyscope for cholangioscopy and biopsy collection identified malignancies with 77% accuracy in patients with suspected cholangiocarcinoma.

Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos)

BACKGROUND

Scant data exist on the utility of the holmium:yttrium-aluminum-garnet laser for the treatment of biliary or pancreatic duct stones.

OBJECTIVE

To evaluate the efficacy and safety of fiberoptic probe and catheter system-guided holmium laser lithotripsy of difficult biliary and pancreatic duct stones.

DESIGN

Prospective study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 64 patients who underwent holmium laser stone fragmentation.

INTERVENTION

A total of 64 patients (60 bile duct stones, 4 pancreatic duct stones) underwent endoscopic retrograde stone fragmentation with a holmium laser and a fiberoptic probe and catheter system. The inclusion criterion for bile duct stones was stones not amenable to retrieval by mechanical lithotripsy and/or balloon sphincteroplasty or standard techniques. Pancreatic duct stones included in this study were not amenable to removal by stone retrieval basket or balloon.

MAIN OUTCOME MEASUREMENTS

Rates of ductal clearance and procedural complications.

RESULTS

All 64 patients had successful fragmentation of biliary and pancreatic duct stones with the holmium laser. Fifty of 60 patients (83.3%) had complete biliary duct clearance after a single session; 10 patients required an additional session. All pancreatic duct stones were fragmented in a single session. Mean duration of ERCP sessions was 45.9 minutes (range 30-90 minutes). Complications were mild and were encountered in 13.5% of patients; fever (n = 3), transient abdominal pain (n = 4), and biliary stricture (n = 1).

LIMITATIONS

No comparative treatment group.

CONCLUSION

The fiberoptic probe and catheter system facilitates transpapillary access for holmium laser fragmentation of difficult biliary and pancreatic duct stones. The technique is safe and highly effective for single-setting duct clearance. Complications are minimal and transient.

Single operator peroral cholangioscopic guided therapy of bile duct stones

Since the introduction of endoscopic sphincterotomy, stone clearance of the bile duct can be achieved by conventional endoscopic means in up to 90% of patients with stone disease. Several endoscopic therapies for difficult bile duct stones have been introduced. Laser therapy for stone fragmentation under direct visual control via the peroral insertion of a cholangioscope (POCS) in the bile duct has proven to be highly effective, further raising the success rate of endoscopic biliary stone clearance. However, conventional POCS has not gained wide acceptance because of several technical limitations such as fragility, impaired steerability and the need for two endoscopists. These limitations may be overcome with a newly developed single operator peroral cholangioscope, the SpyGlass(®) Direct Visualization System. First clinical data of SpyGlass guided intraductal stone fragmentation with EHL or laser fibers report high safety and efficacy of the procedure.

Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope

INTRODUCTION

Peroral cholangioscopy provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother-baby scope system is not widely used because of its disadvantages. Direct peroral cholangioscopy (POC) with a regular, ultra-slim, upper endoscope can provide a valuable and economic solution for evaluating bile duct lesions, although its therapeutic role in biliary tract disease is uncertain. We assessed the usefulness of direct POC with an ultra-slim endoscope for therapeutic application in patients with biliary diseases.

METHODS

Several new techniques and accessories allow therapeutic intervention under direct POC using an ultra-slim upper endoscope with a larger, 2-mm working channel. Intracorporeal laser or electrohydraulic lithotripsy under direct POC is a main therapeutic intervention for patients with bile duct stones resistant to conventional endoscopic procedures. Tumor ablation therapy such as photodynamic therapy and argon plasma coagulation may be performed under direct POC. Direct POC can be applied to guide biliary interventions such as guidewire placement, stone removal, and migrated stent retrieval, using diverse accessories.

CONCLUSION

Direct POC with an ultra-slim upper endoscope allows therapeutic intervention for patients with biliary diseases. Enhancements of the endoscope and specialized accessories are expected to expand the therapeutic role of direct POC.

Direct cholangioscopy-based holmium laser lithotripsy of difficult bile duct stones by using an ultrathin upper endoscope without a separate biliary irrigating catheter

OBJECTIVE

We investigated the impact of direct peroral cholangioscopy (POC)-based holmium laser lithotripsy using an ultrathin endoscope with direct irrigation via a 2-mm-diameter working channel to remove difficult common bile duct (CBD) stones without a separate biliary catheter.

BACKGROUND DATA

Few clinical studies have reported the successful removal of difficult CBD stones by direct POC-based laser lithotripsy using an ultrathin upper endoscope. Previous studies used a separate biliary catheter to ensure continuous irrigation.

METHODS

Ten patients (6 males; mean age 63.3 years) with difficult CBD stones who were not amenable to conventional endoscopic procedures were examined. Direct POC using an ultrathin upper endoscope was performed in all patients. Holmium laser lithotripsy with direct saline irrigation via the operating channel of an ultrathin endoscope was performed until stone fragments were captured in a basket.

RESULTS

The overall success rate of bile duct clearance was 90% (9 of 10 patients) and the mean number of treatment sessions was 1.2 (range, 1-2). Mechanical lithotripsy was performed to complete stone removal in one patient (10%) who had a distal CBD stricture. One patient experienced mild cholangitis following laser lithotripsy.

CONCLUSIONS

Holmium laser lithotripsy under direct POC using an ultrathin upper endoscope may be an effective and safe technique for removal of difficult CBD stones. Direct irrigation via the 2-mm-diameter working channel of the ultrathin endoscope provides sufficient fluid medium and affords good endoscopic viewing to assure stone fragmentation without any need for a separate biliary catheter.

Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos)

BACKGROUND

The feasibility of single-operator cholangioscopy (SOC) for biliary diagnostic and therapeutic procedures was previously reported.

OBJECTIVE

To confirm the utility of SOC in more widespread clinical use.

DESIGN

Prospective clinical cohort study.

SETTING

Fifteen endoscopy referral centers in the United States and Europe.

PATIENTS

Two hundred ninety-seven patients requiring evaluation of bile duct disease or biliary stone therapy.

INTERVENTIONS

SOC examination and, as indicated, SOC-directed stone therapy or forceps biopsy.

MAIN OUTCOME MEASUREMENTS

Procedural success defined as ability to (1) visualize target lesions and, if indicated, collect biopsy specimens adequate for histological evaluation or (2) visualize biliary stones and initiate fragmentation and removal.

RESULTS

The overall procedure success rate was 89% (95% CI, 84%-92%). Adequate tissue for histological examination was secured in 88% of 140 patients who underwent biopsy. Overall sensitivity in diagnosing malignancy was 78% for SOC visual impression and 49% for SOC-directed biopsy. Sensitivity was higher (84% and 66%, respectively) for intrinsic bile duct malignancies. Diagnostic SOC procedures altered clinical management in 64% of patients. Procedure success was achieved in 92% of 66 patients with stones and complete stone clearance during the study SOC session in 71%. The incidence of serious procedure-related adverse events was 7.5% for diagnostic SOC and 6.1% for SOC-directed stone therapy.

LIMITATIONS

The study was observational in design with no control group.

CONCLUSIONS

Evaluation of bile duct disease and biliary stone therapy can be safely performed with a high success rate by using the SOC system.

Preoperative diagnosis of early cystic duct cancer using endoscopic ultrasonography and endocholangioscopy: report of a case

Primary cystic duct carcinoma is a rare condition, for which preoperative diagnosis is difficult. We herein report a case of early primary carcinoma of the cystic duct, which was diagnosed preoperatively using endoscopic ultrasonography and endocholangioscopy. A 76-year-old man was admitted to our hospital with epigastric pain and liver dysfunction. Endoscopic ultrasonography revealed a cystic duct tumor, in diameter of 2.2 cm, which extended to the common bile duct. Endocholangioscopy revealed a well movable papillary tumor at the origin of the cystic duct. The patient underwent cholecystectomy and excision of the extrahepatic bile duct and lymph node. Histological findings confirmed the diagnosis of early papillary adenocarcinoma of the cystic duct.

Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

BACKGROUND

Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery.

METHODS

We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech(®)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists.

RESULTS

There were 4 patients with a median age of 50 (43-69) years. The median duration of the condition prior to PTCSL was 102 (60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130 (125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18 (10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up.

CONCLUSION

PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique.

ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience

BACKGROUND

Comparative data regarding complications associated with ERCP alone or when performed with cholangiopancreatoscopy (CP) are lacking.

OBJECTIVE

To determine whether ERCP complications are more frequent when concomitant CP is performed.

DESIGN

A retrospective query of a prospectively maintained database of ERCP, CP, and complications.

MAIN OUTCOME MEASUREMENTS

Consensus criteria complications and additional adverse events (AEs), including unplanned medical evaluation, cardiopulmonary/sedation events, and others.

SETTING

Academic, tertiary referral center.

RESULTS

A total of 4214 ERCPs were performed (337 sphincter of Oddi manometry cases excluded) during the study period, of which 3475 ERCPs and 402 ERCPs with CP were analyzed. There were 28 of 402 AEs (7.0%) in the ERCP with CP group and 101 of 3475 (2.9%) in the ERCP-only group (odds ratio [OR], 2.50; 95% CI, 1.56-3.89). Subgroup analysis revealed a significantly higher rate of cholangitis in the CP group versus ERCP group (1.0% vs 0.2%; OR, 4.98; 95% CI, 1.06-19.67) and similar rates of pancreatitis (2.2% vs 1.3%; OR, 1.75; 95% CI, 0.74-3.65) and perforation (1.0% vs 0.3%; OR, 3.16; 95% CI, 0.73-10.75).

LIMITATIONS

Retrospective review of a complications database that relies on physician self-reporting.

CONCLUSIONS

AEs from CP may be more than double those of ERCP alone (when sphincter of Oddi manometry cases are excluded). CP appears to be associated with a significantly higher rate of cholangitis, possibly because of intermittent intraductal irrigation required during the procedure.

Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: an analysis of risk factors predicting stone recurrence

BACKGROUND

Peroral cholangioscopy-directed lithotripsy (PC-directed lithotripsy) has been successfully used for the treatment of difficult bile duct stones, including Mirizzi syndrome (MS). However, long-term outcome and risk factors for stone recurrence after PC-directed lithotripsy have not yet been elucidated. The aim of this study was to assess the outcomes of long-term follow-up after PC-directed lithotripsy and to clarify risk factors predicting stone recurrence.

METHODS

One hundred twenty-two consecutive patients with difficult bile duct stones, including MS type II (McSherry classification system), were included in the study.

RESULTS

Successful stone removal was achieved in 117 (95.9%) of the 122 patients treated with PC-directed lithotripsy. Of these 117 patients, reliable follow-up information for a median period of 5.5 years (range=0.19-16.6) was obtained for 111 patients (94.9%) in whom stone type was classified into one of the following three categories: (1) MS type II (47 patients); (2) impacted stones (45 patients); and (3) large stones (≥20 mm in short diameter, 19 patients). Bile duct stone recurrence was observed in 18 patients (16.1%), of whom 4 had MS type II, 9 had impacted stones, and 5 had large stones. Statistical analysis showed that dilated bile duct diameter greater than or equal to 20 mm was the only risk factor for stone recurrence.

CONCLUSIONS

PC-directed lithotripsy used for the treatment of difficult bile duct stones, including MS type II and impacted stones, and is found to be safe at long-term follow-up. Dilated bile duct diameter is the only risk factor for stone recurrence. Careful follow-up is indispensable, particularly for patients with dilated bile ducts.

New options of cholangioscopy

In the evaluation of biliary diseases, cholangioscopy is considered as complementary procedure to radiographic imaging. Direct visualization of the bile duct is the premier advantage of cholangioscopy over indirect imaging techniques. However, cholangioscopy has not gained wide acceptance because of several technical limitations such as scope fragility, impaired steerability, limited irrigation, and suction capabilities, as well as the need for two experienced endoscopists. Recent innovations such as the implementation of electronic video cholangioscopes and the development of single-operator systems facilitate the procedure, and promise to increase the diagnostic and therapeutic yield of cholangioscopy.

Endoscopic treatment of difficult common bile duct stones

Recent developments in treatment devices and advancements in technology have made endoscopic treatment the first choice for bile duct stones. In endoscopic treatment, the stones are removed after expanding the papilla with endoscopic sphincterotomy or endoscopic papillary balloon dilatation. The devices used to remove bile duct stones include basket catheters, balloon catheters and mechanical lithotripters, and their employment varies depending on the clinical situation. Stone removal by endoscopy is superior to other options, although treatment can be difficult in some cases. The reasons are mainly large stones, a history of gastric surgery, and Mirizzi syndrome. For such difficult cases, various adjuvant treatments such as extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy and lasers are recommended rather than using just a mechanical lithotripter. Recently, large-diameter biliary orifice balloon dilation, a method in which the papilla is expanded using a large-diameter balloon, allowing the stones to be removed, has been reported and is attracting increasing attention.

How Should Biliary Stones be Managed?

Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures.

Biliary stenting in the management of large or multiple common bile duct stones

BACKGROUND

Endoscopic biliary stenting with a plastic stent is often performed to prevent impaction of common bile duct (CBD) stones. The therapeutic effect of a plastic stent placement in terms of reduction in stone size and number has not been established.

OBJECTIVE

The aim of this study was to study the effect of biliary stenting as therapy for CBD stones.

DESIGN

Retrospective study.

SETTING

Municipal hospital outpatients.

INTERVENTIONS

Patients with large (> or = 20 mm) and/or multiple (> or = 3) stones had placement of a 7F double-pigtail plastic stent without stone extraction at the initial ERCP. Approximately 2 months later, stone removal was attempted. The number and size of CBD stones before and after stent placement, stone clearance, complications, and 180-day mortality were evaluated.

RESULTS

Forty patients were studied. Stent placement averaged 65 days (range, 50-82 days). The median number (interquartile range) of stones per patient fell after stent placement (4.0 [3.0] before vs. 2.0 [1.0] after; P < .0001). Characteristically, larger stones became smaller and small stones disappeared (ie, the median stone index decreased from 4.6 [3.0] to 2.0 [1.5]; P < .0001). Stone clearance at the second ERCP was achieved in 37 out of 40 patients (93%). Complications included cholangitis (13%) and pancreatitis (5%) after the second ERCP. No 180-day mortality occurred.

LIMITATIONS

A retrospective, single-center study.

CONCLUSIONS

Stent placement for 2 months was associated with large and/or multiple CBD stones becoming smaller and/or disappearing without any complications. Stenting followed by a wait period may assist in difficult CBD stone removal.

A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis

INTRODUCTION

Outcomes after endoscopic sphincterotomy (ES) and subsequent laparoscopic cholecystectomy (LC) versus laparoscopic bile duct exploration (LBDE) during LC are comparable in fit patients with choledocholithiasis. This randomized, clinical trial aimed to determine the optimum treatment in patients with higher medical risk.

MATERIALS AND METHODS

Ninety-one higher risk patients with evidence of bile duct stones were randomized to ES/LC (group A) or LBDE during LC (group B). The primary outcome measure was duct clearance. Secondary outcome measures were complications, number of procedures per patient, conversion, and postoperative hospital stay (POS).

RESULTS

Forty-seven patients were randomized to ES/LC and 44 to LBDE. The median age was 74.56 years. On an intention-to-treat basis, duct clearance was achieved in 29 of 47 of group A and 44 of 44 of Group B patients (P < 0.001). Clavien Grade II-V complications occurred in 8 of 47 and 8 of 44 patients (P = 0.884), the median number of procedures was 2 (2-3) and 1 (1-1) (P < 0.001), 2 of 47 and 4 of 44 patients required conversion (P = 0.676), and the median POS was 3 (2-7) and 5 (2-7) days (P = 0.825), respectively.

CONCLUSIONS

There was no difference between approaches to duct clearance in terms of postoperative stay, complications, or conversion in higher risk patients, but the laparoscopic approach was more effective and efficient and avoided unnecessary procedures.

The successful use of peroral cholangioscopy for the diagnosis and treatment of the biliary tract lesions and giant bile duct stones in a 76-year-old man

We encountered a case in whom peroral cholangioscopy was useful for the diagnosis and treatment of irregular biliary tract mucosa and giant bile duct stones. Peroral cholangioscopy seems to improve the diagnosis of biliary tract diseases and allow internal treatment. The proper diagnosis of biliary tract diseases may be further confirmed by the concomitant use of narrow band imaging and this endoscopic technology.

Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones

OBJECTIVES

Intracorporeal lithotripsy must be used under direct visual control with an additional endoscope in order to ensure safety and precise targeting during the removal of difficult-to-extract bile duct stones using conventional methods. The currently available "mother-baby" scope system has several disadvantages. We evaluated the feasibility and efficacy of direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope for electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) for the treatment of difficult-to-extract bile duct stones.

METHODS

A total of 18 patients who were unsuccessfully treated for common bile duct (CBD) stones using conventional endoscopy, including mechanical lithotripsy (ML), underwent EHL or LL under intraductal balloon-guided direct POC using an ultra-slim upper endoscope. The balloon catheter was used to maintain access while an ultra-slim upper endoscope was advanced directly into the bile duct. EHL or LL was performed until it became possible to capture the fragmented stones in a basket. Endoscopic removal of stone fragments by duodenoscopy was attempted in the same session.

RESULTS

The overall success rate of bile duct clearance by lithotripsy under direct POC by a single endoscopist was 88.9% (16 of 18). Stone fragmentation under direct POC was successfully performed in nine patients using EHL and in seven patients using LL. The average number of treatment sessions required to complete stone removal was 1.6. ML was performed to complete stone removal in 5 of 18 (27.8%) patients. Procedure-related complications were not observed.

CONCLUSIONS

Lithotripsy with EHL or LL under direct POC involving the use of an ultra-slim endoscope by a single endoscopist seems to be an effective and safe treatment for select patients with difficult-to-extract CBD stones.

Choledochoscopy-assisted intraductal shock wave lithotripsy

In more than 90% of choledocholithiasis cases, endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction are successful therapeutic options for clearance of the bile duct with the use of a stone retrieval balloon or basket. However, these techniques fail in a small percentage of patients with biliary stones, and advanced techniques for fragmentation must be used. Intraductal shock wave lithotripsy offers the endoscopist a therapeutic option that may be effective despite the difficulties of a large, impacted stone that cannot be captured by a basket, or a stricture that prohibits delivery of a stone beyond it. This article reviews the use of electrohydraulic lithotripsy and laser lithotripsy in the clinical setting.

Cholangiopancreatoscopy: a comprehensive review

Cholangiopancreatoscopy (CP) is a well-established modality for the direct visualization of intrahepatic biliary, extrahepatic biliary, and pancreatic ductal systems. The use of CP in the treatment of difficult biliary stones has become paramount when standard endoscopic retrograde cholangiopancreatography is ineffective. This article describes the available cholangioscopic devices and technical and clinical applications of cholangiopancreatoscopy. The efficacy and limitations of CP, as well as published comparative studies, are briefly reviewed.

Large size balloon dilation of the ampulla after biliary sphincterotomy can facilitate endoscopic extraction of difficult bile duct stones

GOALS

Evaluate the efficacy and safety of large size balloon dilation of the biliary orifice after maximal biliary sphincterotomy to facilitate removal of difficult bile duct stones in a Western population.

BACKGROUND

Some bile duct stones may be difficult to remove with standard endoscopic retrograde cholangiopancreatography (ERCP) techniques. Even after multiple procedures, and the use of advanced, labor-intense techniques complete stone clearance may be difficult to achieve.

STUDY

This is retrospective review of prospectively collected data. Patients who had failed stone extraction with standard balloon technique after maximal biliary sphincterotomy at the index ERCP underwent large size balloon dilation of the biliary orifice to facilitate stone removal. The main outcomes were complete stone clearance and complications.

RESULT

Forty-four patients were evaluated. Thirty-one (70%) had a prior failed ERCP in the past. Periampullary diverticulum was present in 13 patients (30%). Complete stone removal was accomplished in 42 patients (95%). In 37 patients (84%), complete stone clearance was accomplished at the index ERCP without the need for mechanical lithotripsy. Three patients (6%) required an additional ERCP and 2 patients (5%) required 2 additional ERCPs to accomplish complete stone removal. Three mild complications occurred (6.8%). None of the patients developed perforation or pancreatitis.

CONCLUSIONS

Large size balloon dilation after biliary sphincterotomy is simple, safe, and highly effective technique that can greatly assist in the management of difficult to extract bile duct stones.

Various techniques for the surgical treatment of common bile duct stones: a meta review

Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient' satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities.

Application of per oral cholangiopancreatoscopy in pancreatobiliary diseases

Pancreaticobiliary ductal diseases are largely investigated by indirect imaging techniques. Therefore, the pathology of up to 30% of cases remains undetermined. Cholangiopancreatoscopy allows direct visualization of ductal abnormalities with the ability to sample tissue and deliver a number of endotherapies. The technique can be broadly categorized into either two-operator or single-operator systems. Both systems provide important diagnostic information in the investigation of undetermined biliary or pancreatic strictures, intraductal papillary mucinous neoplasia, occult ductal malignant changes in patients with primary sclerosing cholangitis and occult intraductal stones in patients with complex biliary stone diseases. Therapeutically, cholangiopancreatoscopy-guided endotherapies provide a highly effective and safe alternative to surgery for patients with difficult extrahepatic and intrahepatic ductal stones that are not amenable to conventional endoscopic extraction by endoscopic retrograde cholangiopancreatography. The clinical application of cholangiopancreatoscopy, however, will be limited unless the technology is further refined to improve its durability, image quality, therapeutic capability and technical feasibility.

Cholangioscopy: where are we now?

PURPOSE OF REVIEW

The purpose of this review is to provide an update on current technologies and clinical indications for cholangioscopy. The review also focuses on techniques, challenges and limitations of available devices.

RECENT FINDINGS

Recent technological advances such as the introduction into clinical practice of video cholangioscopes as well as a single-operator semidisposable per oral cholangioscope are described. Novel clinical applications of cholangioscopy are also discussed.

SUMMARY

The past several years have witnessed the emergence of new technologies, including video and semidisposable cholangioscopes, which have increased the availability and utilization of cholangioscopes. Although the most common indications for this technique remain investigation of indeterminate cholangiographic findings and management of large bile duct stones, technological advances in the devices and available accessories will invariably lead to expanded indications in the future.

Management of pancreaticobiliary disease using a new intra-ductal endoscope: The Texas experience

AIM: To evaluate a new single-operator mini-endoscope, Spyglass^®, for its performance, feasibility and safety in the management of pancreaticobiliary disease.

METHODS: In a multicenter retrospective analysis of patients undergoing intraductal endoscopy, we evaluated 128 patients (71 men, mean age 57.6 years). Indications were therapeutic (TX) in 72 (56%) and diagnostic (DX) in 56 (44%).

RESULTS: Peroral endoscopy was performed in 121 and percutaneous in seven. TX indications included CBD stones in 41, PD stones in six, and biliary strictures in 25. DX indications included abnormal LFT’s in 15, abnormal imaging in 38 and cholangiocarcinoma staging in three. Visualization of the stone(s) was considered good in 31, fair in six, and poor in four. Advancement of the electrohydraulic lithotripsy probe was not possible in three patients and proper targeting of the lesion was partial in four patients. A holmium laser was used successfully in three patients. Ductal clearance was achieved in 37 patients after one procedure and in four patients after two procedures. Diagnosis of biliary strictures was modified in 20/29 and confirmed to be malignant in 10/23. Of the modified patients, no diagnosis was available in 17. Spyglass^® demonstrated malignancy in 8/17 and non-malignancy in nine. Suspected pathology by imaging studies and abnormal LFT’s was modified in 43/63 (66%). Staging of cholangiocarcinoma demonstrated multicentric cholangiocarcinoma in 2/3. There was no morbidity associated with the use of Spyglass^®.

CONCLUSION: Spyglass Spyscope^® is a first generation, single operator miniature endoscope that can evaluate and treat various biliary and pancreatic tract diseases.

Intraductal biliary and pancreatic endoscopy: An expanding scope of possibility

Intraductal endoscopy describes the use of an endoscope to directly visualize the biliary and pancreatic ducts. For many years, technological challenges have made performing these procedures difficult. The “mother-baby” system and other various miniscopes have been developed, but routine use has been hampered due to complex setup, scope fragility and the time consuming, technically demanding nature of the procedure. Recently, the SpyGlass peroral cholangiopancreatoscopy system has shown early success at providing diagnostic information and therapeutic options. The clinical utility of intraductal endoscopy is broad. It allows better differentiation between benign and malignant processes by allowing direct visualization and targeted sampling of tissue. Therapeutic interventions, such as electrohydraulic lithotripsy (EHL), laser lithotripsy, photodynamic therapy, and argon plasma coagulation (APC), may also be performed as part of intraductal endoscopy. Intraductal endoscopy significantly increases the diagnostic and therapeutic yield of standard endoscopic retrograde cholangiography (ERCP), and as technology progresses, it is likely that its utilization will only increase. In this review of intraductal endoscopy, we describe in detail the various endoscopic platforms and their diagnostic and clinical applications.

Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos)

BACKGROUND

Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks.

DESIGN

Observational, descriptive.

PATIENTS

Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation.

INTERVENTIONS

Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy.

MAIN OUTCOME MEASUREMENTS

Gallbladder access and visualization, stone clearance, symptom relief, and complications.

RESULTS

The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later.

LIMITATIONS

Proof of concept performed in a single patient.

CONCLUSIONS

Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.

Transpapillary cholangioscopy-directed lithotripsy in patients with difficult bile duct stones

BACKGROUND & AIMS

There are limited prospective data and long-term follow-up on cholangioscopy-directed management of difficult bile duct stones. The study objectives were to evaluate the safety and efficacy of cholangioscopy-directed lithotripsy in patients who had failed standard endoscopic retrograde cholangiopancreatography (ERCP) techniques and to determine the stone recurrence rate.

METHODS

Consecutive patients with biliary stones referred for cholangioscopy after failure of conventional stone therapy were enrolled and followed prospectively.

RESULTS

Between February 2000-October 2004, 32 consecutive patients had cholangioscopy-directed lithotripsy (30 electrohydraulic lithotripsy, 2 mechanical) after a mean of 3.3 (range, 2-14) failed ERCPs. Stones were intrahepatic (N = 8); extrahepatic (N = 18); or both (N = 6). Biliary strictures were present in 20 (63%) patients. Cholangioscopy identified additional stones not seen at ERCP in 9 (28%) patients. A mean of 1.4 lithotripsy sessions achieved complete (N = 26, 81%), partial (N = 5, 16%), or failed (N = 1, 3%) stone clearance. Follow-up was available in 28 (88%) patients for a mean of 29.2 months (95% confidence interval, 20.3-38.1 months). Stone recurrence occurred in 4 of 22 (18%) patients with complete clearance and follow-up data; 3 had primary sclerosing cholangitis. There were 2 minor periprocedural complications and 1 late complication.

CONCLUSIONS

Cholangioscopy-directed lithotripsy is a safe and effective treatment in patients who have failed standard ERCP stone removal techniques. Stone recurrence is low in patients who had complete stone clearance except in patients with primary sclerosing cholangitis. Cholangioscopy detects stones missed by cholangiography.

Pancreatoscopy: present and future role

Current imaging modalities do not allow for direct access to the pancreatic duct. Because of this limitation, diagnosis and assessment of pancreatic diseases require radiographic imaging and cytologic analysis. Although many of these techniques have excellent specificity for the detection of pancreatic cancer, they offer no therapeutic capabilities and are relatively poor in early detection of cancer and in differentiating chronic pancreatitis from malignancy, particularly when the conditions coexist. Currently available cholangioscopes are too large to access the pancreatic duct without sphincterotomy or balloon dilation, increasing the risk of instrumentation trauma to the pancreas. Novel, dedicated pancreatoscopes have recently been developed and are under investigation in clinical trials. Preliminary evidence suggests that these new technologies allow for direct visualization of the pancreatic ducts, with the potential for forceps biopsy in suspected malignancy and endotherapy for pancreatic calculi. Future and ongoing clinical trials will better define the utility and roles of these new endoscopy tools.

SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video)

BACKGROUND

Clinical implementation of cholangioscopy for direct visual examination of bile ducts, tissue sampling, and therapeutic maneuvers has been slowed by limitations in available technology. With 4-way deflected steering and dedicated irrigation channels, the single-operator SpyGlass peroral cholangiopancreatoscopy system is designed to overcome some of these limitations.

OBJECTIVE

To evaluate the clinical utility and safety of the SpyGlass system for diagnostic and therapeutic endoscopic procedures in bile ducts.

DESIGN

Prospective observational clinical feasibility study.

SETTING

Two tertiary referral centers.

MAIN OUTCOME MEASUREMENTS

Procedural success rate defined as the proportion of SpyGlass procedures in which the diagnostic or therapeutic objectives of the procedure were achieved.

RESULTS

SpyGlass procedures were performed in 35 patients: 22 with indeterminate strictures (63%), 5 with indeterminate filling defects (14%), 5 with stones (14%), 2 with cystic lesions (6%), and 1 patient with an indication for gallbladder stent placement (3%). The rate of procedural success was 91% (95% confidence interval 77%-98%). Twenty patients underwent SpyGlass-directed biopsy, and the specimens procured from 19 patients (95%) were found adequate for histologic evaluation. The preliminary sensitivity and specificity of SpyGlass-directed biopsy to diagnose malignancy were 71% and 100%, respectively. SpyGlass-directed electrohydraulic lithotripsy succeeded in 5 of 5 patients (100%). Procedure-related complications occurred in 2 patients (6%) and resolved uneventfully.

LIMITATIONS

No control group was included. Follow-up for determining preliminary sensitivity and specificity was limited.

CONCLUSIONS

SpyGlass procedures proved to be clinically feasible, provided adequate samples for histologic diagnosis, and successfully guided stone therapy. The procedures were safe and well tolerated. Prospective multicenter clinical trials of the system are underway.

Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy

BACKGROUND

Current cholangioscopes are restricted to 2 deflection angles and require more than 1 operator. The newly developed Spyglass peroral cholangiopancreatoscopy system provides 4-way deflected steering by a single operator.

OBJECTIVE

To evaluate access and biopsy in all simulated biliary-duct quadrants with the Spyglass system, high-level disinfection of the reusable Spyglass optical probe, and feasibility of in vivo biopsy.

DESIGN

Laboratory simulations comparing biliary-duct access and biopsy with the Spyglass versus a conventional system, laboratory determination of high-level disinfection effectiveness, and observational investigation of biopsies in a porcine model.

SETTING

Research laboratories.

MAIN OUTCOME MEASUREMENTS

Rate ratios (RR) and 95% confidence intervals (CI) for successful access to all quadrants and simulated biopsy.

RESULTS

Success rates for access in all quadrants were significantly higher with the Spyglass system than with the control system, both without (RR 1.71, 95% CI 1.39-2.29) and with (RR 2.00, 95% CI 1.56-2.78) biopsy forceps loaded. Higher success rates were also attained by using the Spyglass system to access biopsy targets (RR 2.09, 95% CI 1.60-2.91) and to perform simulated biopsies (RR 2.94, 95% CI 2.05-4.52). Microbial species log reductions of 6.0 to 7.0 were achieved by high-level disinfection of Spyglass optical probes. In 31 in vivo porcine biopsies yielding adequate gross specimens, the quality for histologic examination was excellent to adequate for 90% of specimens.

LIMITATIONS

Study procedures were performed by a single nonblinded operator. All data were collected ex vivo or in animals, and clinical applicability remains to be determined.

CONCLUSIONS

The Spyglass system allows access and biopsy in all quadrants and merits clinical investigation.

Peroral cholangioscopy for the diagnosis and treatment of biliary diseases

Peroral cholangioscopy with duodenoscopic assistance can allow direct visualization of the bile duct. Several clinical studies suggest the utility of peroral cholangioscopy for the management of various bile duct lesions. Although direct visual observation may be a useful adjunct to endoscopic retro-grade cholangiopancreatography (ERCP) for distinguishing malignant from benign bile duct lesions, the assessment of diagnostic accuracy needs further controlled clinical studies. Intracorporeal lithotripsy with the use of a peroral cholangioscope may be a safe and effective method for difficult-to-treat bile duct stones, including intrahepatic stones. At present, however, the fragility of the fiberscope equipment and technical difficulties hold back its popularity. Preliminary data obtained by using a new videoscope, which provides excellent quality images, are encouraging. Furthermore, it is expected that this videoscope will have longer durability of optical images and better manipulation than previous fiberscopes.

Updates in biliary endoscopy

PURPOSE OF REVIEW

Endoscopic retrograde cholangiopancreatography is a non-surgical approach to diseases of the pancreaticobiliary system that dates back to the late 1960s. Initially, endoscopic retrograde cholangiopancreatography was purely a diagnostic procedure. After the first report of endoscopic sphincterotomy in 1974, therapeutic uses were possible for diseases that previously required surgery. As therapeutic indications broaden, our understanding of complications has tempered the initial excitement. Non-invasive imaging in many circumstances has replaced the diagnostic utilization of endoscopic retrograde cholangiopancreatography which is now reserved primarily for therapeutic indications. This review is intended to address biliary therapeutics with an update on the recent directions of this field.

RECENT FINDINGS

Advancements in the endoscopic retrograde cholangiopancreatography medical literature in the last year have concentrated on the management of difficult common bile duct stones using electrohydraulic lithotripsy, chronic pancreatitis and pancreatic cancer-induced biliary strictures, postoperative bile leaks, the use of newer methods of biliary access and finally the use of ulinastatin for the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.

SUMMARY

This is an update of the work in the field of biliary endoscopy over the last year. The goal of this review is to address specific management concerns in the field of biliary endoscopy from the literature published in 2005.

Difficult bile duct stones

Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.

Clearance of irretrievable bile duct and pancreatic duct stones by extracorporeal shockwave lithotripsy, using a transportable device: effectiveness and medium-term results

BACKGROUND AND GOALS

Extracorporeal shockwave lithotripsy (ESWL) is an established treatment of irretrievable biliary and pancreatic stones, but the cost of the shockwave generators limits its widespread use. We revised data about the effectiveness of our treatment for refractory stones using a transportable shockwave generator.

STUDY

We retrospectively evaluated the short and medium-term outcomes of patients who underwent ESWL using a transportable electromagnetic shockwave generator between 1998 and 2003 at our unit, for the treatment of irretrievable bile duct or pancreatic duct stones. All patients received intravenous conscious sedation and antibiotic prophylaxis.

RESULTS

Complete stone clearance was achieved in 70/82 patients (85.4%), in 66 of the patients (94.2%) with 1 session of ESWL. Despite the insertion of a stent in the bile duct, 2 patients had moderate cholangitis, while they waited for the next ESWL session. We did not record any moderate-severe complication of ESWL, but 2 patients underwent surgery owing to perforation/bleeding during endoscopic removal of residual fragments. A symptomatic recurrence of stones was recorded in 10/69 (14.5%) patients, who had been previously cleared and whose follow-up data (median follow-up 29 mo; range 7 to 66) were available.

CONCLUSIONS

We obtained satisfactory stone clearance by using a transportable shockwave generator. Most patients required 1 session. Our experience confirmed the safety of the treatment, even though patients may experience cholangitis while awaiting definitive treatment. The use of a transportable ESWL generator may be a valuable option in centers, while ensuring a sufficient proficiency in biliary endoscopy.