Uncomplicated common bile duct stone removal guided by cholangioscopy versus conventional endoscopic retrograde cholangiopancreatography

Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis

Radiation-free one-stage bedside endoscopic stone removal and biliary drainage for severe acute cholangitis (SAC) caused by choledocholithiasis in intensive care unit (ICU) has not been reported. Herein, we introduce our preliminary experience of such intervention. Radiation-free bedside digital cholangioscope-assisted one-stage endoscopic stone removal and biliary drainage was performed in an urgent manner. Data on clinical outcomes and follow-up from thirty patients were retrospectively analyzed. Time interval was 7.6 ± 4.7 (2-18) h between ICU admission and endoscopic intervention, and was 35.5 ± 14.5 (5-48) h between the seizure and endoscopic intervention. A 100% technical success was achieved. Except for one mild pancreatitis, no other complication occurred. Patients showed good responses to endoscopic interventions, which were reflected by ameliorated disease severities and laboratory findings. Time lengths of ICU stay and total in-hospital stay were 8.7 ± 4.9 (2-23) days and 14.5 ± 7.4 (5-39) days, respectively. In-hospital mortality occurred in three patients. According to a 6-month follow-up, two patients died of pneumonia and acute myocardial infarction. No SAC and/or biliary stone residual occurred. The current intervention demonstrated favorable results compared to traditional endoscopic retrograde cholangiopancreatography. Our study provides a novel bedside endoscopic intervention method for SAC caused by choledocholithiasis.

Endoscopic clearance of non-complex biliary stones using fluoroscopy-free direct solitary cholangioscopy: Initial multicenter experience

Background and Aims

Fluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial.

Methods

Twelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard.

Results

Fully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient.

Conclusions

In patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340).

Digital cholangioscopy-assisted, direct visualization-guided, radiation-free, endoscopic retrograde intervention for cholelithiasis: technical feasibility, efficacy, and safety

BACKGROUND

Nonradiation, digital cholangioscope (DCS)-assisted endoscopic intervention for cholelithiasis has not been widely performed. For this study, we aimed to report the feasibility, efficacy, and safety of an established DCS-guided lithotomy procedure.

METHODS

Data relating to biliary exploration, stone clearance, adverse events, and follow-up were obtained from 289 patients. The choledocholithiasis-related outcomes via the DCS-guided procedure were subsequently compared to those via conventional endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Biliary access was achieved in 285 patients. The technical success rate for the exploration of the common bile duct, the cystic stump, the hilar ducts, and secondary radicals was 100%. Moreover, the success rates were 98.4%, 61.7%, and 20.7%, for the exploration of the cystic duct, complete cystic duct, and gallbladder, respectively. Suspicious or confirmed suppurative cholecystitis, cholesterol polyps, and hyperplastic polyps were detected in 42, 23, and 5 patients, respectively. Stone clearance was achieved in one session in 285 (100%), 11 (100%), 13 (100%), 7 (100%), 6 (100%), and 3 (14.3%) patients with choledocholithiasis and hepatolithiasis, cystic duct stump stones, nondiffuse located intrahepatic lithiasis, a single cystic duct stone, a single gallbladder stone, and diffuse located intrahepatic lithiasis, respectively. Complete stone clearance for diffuse intrahepatic lithiasis was achieved in 19 (90.5%) patients, and fractioned re-lithotomy was performed in 16 (76.2%) patients. One patient developed mild acute cholangitis, and 12 developed mild pancreatitis. Stones recurred in one patient. Compared with conventional ERCP, DCS-guided lithotomy has the advantages of clearing difficult-to-treat choledocholithiasis and revealing concomitant biliary lesions, and this technique has fewer complications and a decreased risk of stone recurrence.

CONCLUSIONS

The technical profile, efficacy, and safety of nonradiation-guided and DCS-guided lithotomy are shown in this study. We provide a feasible modality for the endoscopic removal of cholelithiasis.

SEED Consensus Document on SpyGlass-DS

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.

Digital Cholangioscopy-assisted Nonradiation Endoscopic Retrograde Cholangiopancreatography for Retrieval of Common Bile Duct Stone

BACKGROUND

The use of nonradiation endoscopic retrograde cholangiopancreatography (NR-ERCP) for choledocholithiasis is still limited. Hereby, we introduced our experience of digital cholangioscopy (DCS)-assisted NR-ERCP for retrieval of common bile duct stones.

METHODS

Altogether, data of 132 patients who underwent DCS-assisted NR-ERCP for choledocholithiasis were collected. Procedure details, complications, and short-term follow-up were reviewed and analyzed and were compared with those of conventional endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Routine stone extraction and laser lithotripsy were planned in 116 and 16 patients, respectively. Biliary access was successfully achieved by standard biliary cannulation and by advanced techniques in 99 and 33 patients, respectively. Complete stone removal was achieved in a single session in all patients. Routine stone extraction was performed in 117 patients, and laser lithotripsy was applied in 15 patients, among whom 14 patients with planned lithotripsy and 1 unexpected impacted stone found during the procedure. Unexpected right localized intrahepatic stones and purulent cholecystitis were found in 1 and 3 patients, respectively. Three mild and 1 moderate pancreatitis, 5 cases of hyperamylasemia, and 2 cases of leukocytosis occurred as complications. Short-term follow-up revealed no stone residual. Procedure details, technical success, and complications were not statistically different than conventional ERCP.

CONCLUSIONS

DCS-assisted NR-ERCP is technically feasible, efficient, and safe for retrieval of common bile duct stones. This novel method is superior to conventional ERCP on detecting unexpected concomitant biliary diseases.

Tactics and techniques of choledochal sanation after papillotomy

Сholelithiasis ranks third in terms of the prevalence of diseases among the adult population. A complication such as choledocholithiasis occurs in up to 33% of patients with gallstone disease. Despite the improvement in treatment methods and the use of “gold” standards, the number of complicated forms of cholelithiasis has no tendency to decrease. Timely resolution of choledocholithiasis by a correctly chosen technique helps to reduce complications and increases the frequency of favorable outcomes of the disease, returning patients to social activity.

That is why it is important to know and, if possible, to use various methods of rehabilitation of the common bile duct when performing modern endoscopic transpapillary interventions.

Radiation-free digital cholangioscopy-guided laser lithotripsy for large common bile duct stones: feasibility and technical notes

AIMS

Although endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones is facilitated by digital cholangioscopy-guided lithotripsy, it is performed by fluoroscopy guidance. Here, we report our experience of non-radiation ERCP for large CBD stones using digital cholangioscopy-guided laser lithotripsy.

METHODS

Sixteen patients with large CBD stones underwent non-radiation digital cholangioscopy-guided laser lithotripsy and lithotomy. Data relevant to procedure details, adverse events, and short-term follow-up were analyzed.

RESULTS

Biliary access was achieved in all patients using standard guidewire-assisted cannulation, double-guidewire technique, and transpancreatic precut in twelve, two, and two patients, respectively. Balloons of 10 mm, 8 mm, and 6 mm in diameter were applied for EPBD in 8, 2, and 6 patients, respectively. Complete stone removal in one session was achieved in all patients. One round of laser lithotripsy was needed for stone ≤ 25 mm, and three-to-five rounds were needed for stones > 25 mm or multiple stones. One or two clips were used for endoscopic clipping. The time lengths of biliary access, digital cholangioscopy-assisted laser lithotripsy and stone extraction, and whole procedure were 3.5 ± 3.2 (0.5-12) minutes, 52.5 ± 30.6 (45-97) minutes, and 76 ± 23.3 (58-106) minutes, respectively. Asymptomatic hyperleukocytose, hyperamylasemia, and mild pancreatitis were present in 1, 2, and 1 patient(s), respectively. No other complications occurred. No cholangitis or recurrent CBD stones were observed.

CONCLUSION

Non-radiation digital cholangioscopy-guided laser lithotripsy is technically feasible and can be safely performed for endoscopic management of large CBD stones.

Percutaneous Transhepatic Papillary Balloon Dilation versus Endoscopic Retrograde Cholangiopancreatography for Common Bile Duct Stones: A Multicenter Prospective Study

Background Endoscopic retrograde cholangiopancreatography (ERCP) is recommended by major guidelines for the removal of common bile duct (CBD) stones but is technically challenging in patients with low cardiopulmonary reserve and anatomic abnormalities of the upper gastrointestinal (GI) tract. Purpose To compare percutaneous transhepatic papillary balloon dilation (PTPBD) with ERCP for CBD stone removal. Materials and Methods Participants with one to three CBD stones (largest stone ≤30 mm) and without intrahepatic bile duct or gallbladder stones were eligible for this prospective cohort study. PTPBD was recommended in participants with low cardiopulmonary reserve or definitive anatomic abnormalities of the upper GI tract. Otherwise, both procedures were offered without preference. Follow-up, including abdominal CT, was conducted at 1-week and 1-, 3- and 6-month follow-up, and every 6 months thereafter. US and MR cholangiopancreatography were conducted if recurrence could not be confirmed with CT. Technical success rate was the primary outcome. Results A total of 531 participants were analyzed: there were 360 undergoing PTPBD (median age, 76 years; interquartile range [IQR], 64-82 years; 163 men) and 171 undergoing ERCP (median age, 66 years; IQR, 57-74 years; 94 men). The technical success rate was 99% (355 of 360) in the PTPBD group and 98% (167 of 171) in the ERCP group (relative risk, 1.02; P = .12). The incidence of overall complications was 4% (13 of 360) for PTPBD and 8% (13 of 171) for ERCP (relative risk, 0.27; 95% CI: 0.12, 0.61; P < .001). The PTPBD group showed a longer fluoroscopy time and a higher radiation exposure, with adjusted differences of 28.7 minutes (95% CI: 22.2, 35.2) and 384.3 mGy (95% CI: 296.5, 472), respectively. A propensity score-matching analysis (n = 123 per group) indicated that PTPBD had a slightly higher technical success rate and significantly fewer complications. Conclusion When compared with endoscopic retrograde cholangiopancreatography, percutaneous transhepatic papillary balloon dilation has a similar technical success rate and fewer perioperative complications but a higher radiation exposure. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by van Sonnenberg and Mueller in this issue.

Single-operator peroral cholangioscopy cystic duct cannulation for transpapillary gallbladder stent placement in patients with acute cholecystitis at moderate to high surgical risk (with videos)

BACKGROUND AND AIMS

One of the main reasons for failed endoscopic transpapillary gallbladder stenting (ETGS) under fluoroscopic guidance is the inability to cannulate the cystic duct. Single-operator peroral cholangioscopy (SOC)-assisted ETGS is an adjunct technique to facilitate ETGS. We aimed to demonstrate its efficacy.

METHODS

Between 2015 and 2019, 104 patients with acute cholecystitis at moderate to high surgical risk underwent ETGS, which involved 3 steps: (1) cystic duct cannulation under fluoroscopic guidance with or without additional SOC guidance; (2) guidewire placement; and (3) stent placement in the gallbladder. The technical success rate was determined when stent placement was confirmed endoscopically and radiographically.

RESULTS

Of 104 patients, 55 (53%) patients had successful ETGS under fluoroscopic guidance. Of 49 patients who had failed fluoroscopy-guided ETGS, 41 patients underwent additional SOC-assisted ETGS and 5 patients proceeded to other interventions. Of patients who underwent SOC-assisted ETGS (n = 41), 23 (56%) cystic cannulation followed by stent placement were successful; cystic duct cannulations, guidewire, and stent placement failed in 8, 9, and 1 patients, respectively. The overall technical success rate of ETGS increased from 53% (55 of 104) to 75% (78 of 104) after additional SOC assistance. Adverse events and recurrence were not different between patients who underwent ETGS under fluoroscopic guidance and those who underwent SOC-assisted ETGS.

CONCLUSIONS

In patients with acute cholecystitis who are not surgical candidates, SOC-assisted ETGS can increase the technical success rate after failed fluoroscopic guidance. SOC can help for the cystic duct cannulation and guidewire placement steps but not for the stent placement step.

Endoscopic Self-Expandable Metallic Stent Insertion without Fluoroscopic Guidance Is Feasible and Safe for Acute Colonic Obstruction Caused by Colorectal Cancer

Aims

Endoscopic self-expandable metallic stent (SEMS) insertion for acute colonic obstruction caused by colorectal cancer (CRC) is always performed under fluoroscopic guidance. This study evaluated the feasibility and safety of an endoscopic stenting procedure without fluoroscopic guidance.

Methods

A total of 36 patients with an acute colonic obstruction caused by CRC underwent endoscopic SEMS insertion using a colonoscope without fluoroscopic guidance, followed by analyses of the technical and clinical success and short-term complications.

Results

Total technical success rate and clinical success rate were 91.7% and 86.1%, respectively. The mean procedure time was 21.2 ± 10.3 minutes. There was no stent dislodgement. One case of hematochezia and two cases of tenesmus occurred in patients with left-sided complete obstructions. No other short-term complications occurred. Procedure time, technical success, and clinical success rate were 16.3 ± 9.4 minutes, 93.1%, and 89.6% for left-sided obstructions, respectively, and were 26.8 ± 10.7 minutes, 85.7%, and 71.4% for right-sided obstructions, respectively. For complete obstructions, procedure time, technical success, and clinical success rate were 22.5 ± 8.9 minutes, 90%, and 83.3%, respectively. In the incomplete cases, procedure time, technical success, and clinical success were 13.5 ± 6.7 minutes, 100%, and 100%, respectively. Technical success, clinical success, and short-term complications were not differed between lesion locations and degrees.

Conclusions

This simple technique is feasible and safe for palliation of acute colonic obstruction caused by CRC.

Biliary interventions using single-operator cholangioscopy

Cholangioscopy provides an opportunity to directly visualize the bile duct for diagnosing biliary lesions and for therapeutic interventions. Although there are different cholangioscopy techniques available, single-operator cholangioscopy has gained widespread acceptance as the standard technique for interventions in the biliary system because of its ease of use and widespread availability. Single-operator cholangioscopy can be used for both diagnostic and therapeutic indications in the biliary tract. Diagnostic cholangioscopy is used for direct evaluation of indeterminate bile duct strictures with biopsies, diagnosing filling defects in the bile ducts observed during endoscopic retrograde cholangiography (ERC) imaging, preoperative mapping of the precise location and extension of tumors of the biliary tract, and diagnosis of intraductal neoplasms. Therapeutic cholangioscopy is used for visually guided treatment of biliary stones that have failed extraction with conventional ERC techniques, residual or impacted stones by using intraductal lithotripsy, ablation of biliary tumors and for facilitation of guidewire advancement into selective intrahepatic ducts for adequate biliary drainage. In this review, we will focus on advances in the single-operator cholangioscopy techniques in the diagnosis and management of biliary disorders.

The emerging role of non-radiation endoscopic management of biliary tract disorders

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic technique into a therapeutic-centered modality for managing biliary disorders. Despite its many therapeutic benefits, radiation exposure from ERCP fluoroscopy is of concern and should be minimized as much as possible. Although the use of personal equipment offers significant protection against radiation, attention has been given to the development of non-radiation-based ERCP techniques. To this end, digital cholangioscopy and endoscopic ultrasound-assisted ERCP have emerged as alternatives to standard ERCP. Both techniques have sufficient feasibility and potential diagnostic accuracy to eliminate the need for fluoroscopy. Here we discuss the advances in non-radiation ERCP techniques and their role in the management of biliary stones.