Clinical role of frequency-doubled double-pulsed yttrium aluminum garnet laser technology for removing difficult bile duct stones (with videos)

Favorable impact of a novel endoscopic auxiliary system (NEAS) on fluoroscopy-guided lithotripsy for difficult bile duct stones: A pilot study

OBJECTIVES

Laser lithotripsy under fluoroscopic guidance is difficult to perform and risky due to its invisibility. In this study we aimed to investigate the efficacy and safety of a novel endoscopic auxiliary system (NEAS)-assisted lithotripsy under fluoroscopy for treating difficult common bile duct (CBD) stones.

METHODS

Patients with difficult CBD stones who were treated with NEAS-assisted laser lithotripsy (NEAS group) or conventional mechanical lithotripsy (ML) under fluoroscopy (ML group) were retrospectively evaluated. The primary outcome was the complete stone clearance rate and the secondary outcomes included operation time, complications, and medical cost.

RESULTS

Seventeen patients were treated with NEAS-assisted laser lithotripsy and 144 patients underwent ML. Using the propensity score matching analysis, 17 pairs of cases treated with NEAS-assisted lithotripsy and ML were included. Patients in the NEAS group showed a higher stone clearance rate than the ML group (94.1% vs 58.8%, P = 0.039), as well as shorter operation time (41.9 min vs 49.4 min, P < 0.001) and lower medical cost (USD 4607 vs USD 5014, P < 0.001). There was no significant difference in the complication rate between the two groups (5.9% vs 17.6%, P = 0.601).

CONCLUSION

NEAS-assisted fluoroscopy-guided laser lithotripsy is feasible and safe, which may be a promising technique in fluoroscopy-guided laser lithotripsy for difficult CBD stones.

[SpyGlass cholangioscopy – first experiences]

Összefoglaló. Bevezetés: A SpyGlass-kolangioszkópia újonnan kifejlesztett endoszkópos technika, mely az epeutak közvetlen vizualizációját teszi lehetővé. A kolangioszkóp egy 10,8 Fr átmérőjű, a duodenoszkóp munkacsatornáján keresztül az epeútba vezethető, a különböző endoszkópos tartozékok számára saját munkacsatornával bíró endoszkóp. Fő indikációs területe a bizonytalan dignitású epeúti szűkületek diagnosztikája, valamint a konvencionális endoszkópos technikával nem megoldható epeúti kövesség terápiája. Célkitűzés: Célunk a SpyGlass berendezés hasznosságának és hatásosságának megítélése. Módszer: A Jahn Ferenc Dél-pesti Kórház Gasztroenterológia Osztályán 2018. január 1. és 2020. december 31. között a Spyglass DS I, míg 2021 januárjában a SpyGlass DS II rendszert használtuk. 14 diagnosztikus és 15 terápiás beavatkozást végeztünk. A diagnosztikus beavatkozások beválogatási kritériuma azon bizonytalan dignitású epeúti szűkületeket fogalta magában, melyek esetén a végső diagnózis korábban elvégzett endoszkópos retrográd kolangiopankreatográfiával vagy endoszkópos, ultrahangvezérelt szövettani mintavétellel nem volt megállapítható. A terápiás beavatkozás indikációja a konvencionális endoszkópos technikával nem megoldható epeúti kövesség volt. Eredmények: A makroszkópos megítélés és a végső diagnózis egyezésének tekintetében a kolangioszkópia pontossága 85% volt. A szövettani diagnózis pontossága kolangioszkópvezérelt biopsziák esetén 62,5%. A makroszkópos diagnózis szenzitivitása 100%, specificitása 71% volt, a szövettani minták szenzitivitása 60%, specificitása 100% volt. Komplett clearence-t 4 esetben értünk el, ez összesen 57,14% sikerességi rátának felel meg. Következtetés: A SpyGlass-vizsgálat lehetővé teszi a bizonytalan eredetű epeúti szűkületek pontos értékelését, valamint megkönnyíti a szövettani mintavételezést. A diagnosztikus specificitás és szenzitivitás tekintetében a nemzetközi irodalmi adatok eléréséhez további fejlődés és az esetszámok növelése szükséges. A SpyGlass-vezérelt elektrohidraulikus lithotripsia a konvencionális endoszkópos technikával nem megoldható nehéz epeúti kövek kezelési alternatívája. Orv Hetil. 2022; 163(4): 150-156 Summary.

INTRODUCTION

SpyGlass cholangioscopy is a recently developed endoscopic technique to the direct visualization of the biliary tract. The SpyGlass cholangioscop is a 10,8 Fr diameter endoscop which can be guided to the biliary tract through the work channel of the doudenoscope and has its own work channel for the different endoscopic accessories. The main indications of the examination are the diagnosis of the uncertain dignity biliary stenosis and the therapy of the biliary stones which failed conventional therapy.

OBJECTIVE

Our aim was to assess the utility and efficacy of the SpyGlass system.

METHOD

In Jahn Ferenc South Pest Hospital Gastroenterology Department, we used the SpyGlass™ DS I system between 2018 and 2020 and from 2021 the SpyGlass™ DS II. 14 diagnostic and 15 therapeutic Spyglass procedures have been performed. Inclusion criterion of diagnostic procedures was indeterminate bile duct stenosis where the final diagnosis could not be confirmed by endoscopic retrograde cholangiopancreatography or endoscopic ultrasound-guided biopsy. Inclusion criteria of the therapeutic examinations were difficult bile duct stones which failed conventional therapy.

RESULTS

Concerning the correspondence of the macroscopic image and the final diagnosis, the accuracy of the cholangioscope was 85%. The accuracy of the histological diagnosis in the case of cholangioscopy-guided biopsies was 62.5%. The sensitivity of the macroscopic diagnosis was 100%, specificity was 71%, while the sensitivity of histologic samples was 60% and the specificity was 100%. Complete clearence was performed four times in the case of therapeutic procedures, which refers to 57.14% success rate.

CONCLUSION

The use of SpyGlass enhances the precise evaluation of indeterminate bile duct lesions and tissue acquisition is easier to perform. However, to reach the international standards of diagnostic sensitivity and specificity, further improvement and examinations are necessary. Spyglass-guided electrohydraulic lithotripsy is an alternative for difficult stones which failed conventional therapy. Orv Hetil. 2022; 163(4): 150-156.

Fluoroscopy-guided percutaneous lithotripsy using FREDDY laser for giant gallstones: Preliminary experience

OBJECTIVES

Percutaneous treatment of symptomatic cholelithiasis with large gallstones remains a challenge. We aimed to evaluate the efficacy and safety of a new method for the removal of giant gallstones with percutaneous lithotripsy using a frequency-doubled double-pulse neodymium: YAG (FREDDY) laser.

MATERIALS AND METHODS

This study included 16 patients (7 males, 9 females; mean age, 63.4 ± 14.9 years) with giant gallstones who experienced the recurrence of cholecystitis and were not eligible for operation. The percutaneous transcystic approach was established using an 8-French sheath. A 6-French steerable sheath were inserted through the sheath. FREDDY laser lithotripsy was performed to break the stones into fragments. The stone fragments were extracted through the 6-French sheath or pushed into the duodenum using a balloon catheter. Cholecystography was performed before removing the catheter. Follow-up ultrasound or computed tomography examination were performed.

RESULTS

Gallstone clearance was accomplished in 16 (100%) patients at the initial assessment. Eleven patients underwent one session, and five patients underwent two sessions. Residual stones were found in 3 (18.8%) patients during the follow-up period. Peritonitis was found in two (12.5%) patients and hemocholecyst was detected in one (6.3%) patient. No procedure-related deaths occurred.

CONCLUSION

Percutaneous lithotripsy using a FREDDY laser may be an effective and safe alternative choice for treating giant gallstones, especially for patients who are not eligible for cholecystectomy.

Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones - A prospective study from a tertiary care centre in Eastern India

BACKGROUND AND STUDY AIMS

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.

PATIENTS AND METHODS

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.

RESULTS

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.

CONCLUSION

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

Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis

INTRODUCTION

Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates.

AIM

To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy.

METHODS

Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies.

RESULTS

Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%).

CONCLUSIONS

For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.

Laparoscopic transcystic common bile duct exploration: surgical indications and procedure strategies

BACKGROUND

LTCBDE combined with or without modified techniques is safe and efficacious for the management of gallstones and concomitant, even large, common bile duct (CBD) stones.

METHODS

To describe the surgical indications and procedure strategies of laparoscopic transcystic common bile duct exploration (LTCBDE), a retrospective analysis of 205 patients with concomitant gallstones and CBD stones treated using LTCBDE between June 2008 and June 2015 was performed. Clinical data on disease characteristics, methods for cystic duct incision and CBD stone extraction (with or without laser lithotripsy), and surgical outcomes were collected and reviewed.

RESULTS

CBD stones were successfully cleared in all patients. No patient was converted to choledochotomy or laparotomy. The cystic duct diameter ranged 3-8 mm, and 85 patients with cystic duct diameter ≥ 5 mm. The mean time for CBD stone extraction was 25.3 min, with the operative time ranged from 63 to 170 min. Lithotripsy was used in 74 (36.1%) patients among which 26 patients with cystic duct diameter ≥ 5 mm. Estimated blood loss during surgery was 10-120 ml per patient, and no intra-operative blood transfusions were needed. The mean postoperative hospital stay was 5.1 (range 3-7) days, and postoperative complications developed in seven patients. No bile duct injury, stricture, remnant, recurrent stones, or other adverse events were observed during the mean follow-up of 8 months.

CONCLUSIONS

Based on preoperative MRCP and intra-operative IOC findings about cystic duct diameter, the diameter of CBD, CBD stone size, we summarized and proposed the surgical indications and suitable techniques and strategies during LTCBDE.

A clinical study of choledochoscopic holmium laser lithotripsy for multiple intrahepatic calculi within ERAS programs

OBJECTIVES

Multiple intrahepatic calculi, especially calculi in both sides of the liver, cannot be completely resolved by traditional surgery. In addition, morbidity after liver resection remains high. ERAS programs have been suggested that could relieve surgical stress and accelerate postoperative recovery. This study aimed to evaluate the safety and efficacy of choledocholithotomy combined with holmium laser lithotripsy in the treatment of multiple intrahepatic calculi within ERAS programs.

METHODS

In all, 109 patients with multiple intrahepatic calculi were enrolled between January 2012 and September 2016, 42 of whom received choledocholithotomy combined with holmium laser lithotripsy. The remaining 67 patients underwent choledocholithotomy combined with choledochoscopic mechanical lithotripsy. Perioperative outcomes were compared and analyzed.

RESULTS

Patient characteristics and preoperative details were similar between the groups (P > 0.05). The implementation of holmium laser lithotripsy could reduce the calculi residual rate (7.1% vs. 22.4%, P = 0.037), and even the liver resection rate (16.7% vs. 35.8%, P = 0.031). Additionally, holmium laser lithotripsy did not result in a higher morbidity (11.9% vs. 16.4%, P = 0.517), readmission rate (0% vs. 6%, P = 0.158), hospital stay (P = 0.189), hospital cost (P = 0.998), transfusion rate (P = 0.576), or operative time (P = 0.638).

CONCLUSIONS

Holmium laser lithotripsy is feasible and efficient for treating multiple intrahepatic calculi within ERAS programs, which could reduce the liver resection rate and render refractory hepatic calculi easy to eliminate. In addition, holmium laser lithotripsy could be well coupled to the ERAS program to relieve surgical stress and accelerate postoperative recovery. Lasers Surg. Med. 51:161-166, 2019. © 2018 Wiley Periodicals, Inc.

Management of impacted common bile duct stones during a laparoscopic procedure: A Retrospective Cohort Study of 377 Consecutive Patients

INTRODUCTION

To explore the techniques for managing impacted common bile duct (CBD) stones during laparoscopic common bile duct exploration (LCBDE).

METHODS

We retrospectively analyzed 377 consecutive patients undergoing LCBDE from January 2008 to June 2015. Group 1 was defined as patients with impacted CBD stones. Group 2 included patients without impacted CBD stones. The outcomes of LCBDE were compared between the two groups.

RESULTS

There were 65 patients in Group 1 and 312 patients in Group 2. The incidence of jaundice, abnormal liver function tests, cholangitis and pancreatitis was higher in Group 1. Forty-one patients with small impacted CBD stones were managed using the tipless Nitinol basket. Seventeen patients with large impacted CBD stones and 7 patients with small impacted CBD stones underwent laser lithotripsy via choledochoscopy. None of the patients in Group 1 was converted to open procedures for impacted CBD stones. Operation duration was 13.6 min longer in Group 1 (133.2 min). Postoperative hospital stay was significantly longer in Group 1 (9.7 ± 2.5 d) than in Group 2 (6.3 ± 1.8 d). There was no difference in the overall postoperative complication rate, retained stone rate, and recurrence rate between the two groups.

CONCLUSION

Rational utilization of laser lithotripsy and an appropriate basket in LCBDE may avoid conversion to open procedures in patients with impacted CBD stones.

Laparoscopic Transcystic Common Bile Duct Exploration: T-Shaped Incision of Cystic Duct with FREDDY Laser Lithotripsy

OBJECTIVES

Optimal laparoscopic techniques for management of gallstones concomitant with common bile duct (CBD) stones remain under debate. The aim of this study was to evaluate a novel approach to managing gallstones concomitant with large or impacted CBD stones through a modified laparoscopic transcystic CBD exploration (LTCBDE) with frequency-doubled double-pulse neodymium:YAG (FREDDY) laser lithotripsy.

MATERIALS AND METHODS

This retrospective review includes 32 consecutive patients with gallstones concomitant with large or impacted CBD stones who were offered LTCBDE with FREDDY laser lithotripsy between June 2012 and December 2014. Demographic, perioperative, and follow-up data were collected and analyzed retrospectively.

RESULTS

CBD stone clearance was achieved for all patients. There were 13 males and 19 females, among whom there were three patients with a history of abdominal surgery. The diameter of the CBD ranged from 10 to 20 (mean 15.1) mm, and the number of CBD stones ranged from 1 to 5. CBD stones ranged in diameter from 9 to 18 (mean 11.7) mm and 9 patients had stones that were impacted in the CBD. The mean operative time was 123 ± 18 minutes with a range of 72 to 155 minutes. The mean length of postoperative hospital stay was 5.3 (range 4-7) days. All patients recovered normally without morbidity or mortality.

CONCLUSIONS

The modified LTCBDE with a T-shaped incision of the cystic duct and FREDDY laser lithotripsy is a safe and effective means of managing gallstones concomitant with large or impacted CBD stones.

Management hepatolithiasis with operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy

BACKGROUND

Hepatolithiasis is very common in East Asia. It is benign in nature, but has a high recurrence rate. It is likely to lead to biliary cirrhosis and increase the risk of cholangiocarcinoma. Hence, the treatment of hepatolithiasis is difficult but vital. In this report, we present a novel approach to manage hepatolithiasis using the choledochoscopic Frequency-Doubled Double pulse Nd:YAG (FREDDY) laser lithotripsy combined with or without hepatectomy.

METHODS

Between July 2009 and October 2012, 45 patients underwent choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy (laser lithotripsy group). Forty-eight patients underwent a traditional operation (traditional method group) from January 2009 to June 2009. Comparative analysis was made of demographic and clinical characteristics of the two groups.

RESULTS

The final stone clearance rate of the laser lithotripsy group was 93.3%, whereas that of the traditional method group was 85.4% (P=0.22). In the laser lithotripsy group, 2 patients experienced hemobilia and 3 patients had acute cholangitis. In the traditional method group, 3 patients had intraoperative hemorrhage, 1 patient had bile leakage, 6 patients had acute cholangitis, and 1 patient died of liver failure. Moreover, the operative time in the traditional method group was significantly longer than that in the laser lithotripsy group (P=0.01). The mean hospital stay of the patients in the traditional method group was longer than that in the laser lithotripsy group (9.8 vs 8.2 days, P=0.17). Recurrent intrahepatic bile duct stones were not found during the follow-up period in the two groups.

CONCLUSION

Operative choledochoscopic FREDDY laser lithotripsy combined with or without hepatectomy may be an effective and safe treatment for hepatolithiasis.

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.

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.

Holmium laser lithotripsy under direct peroral cholangioscopy by using an ultra-slim upper endoscope for patients with retained bile duct stones (with video)

BACKGROUND

Direct peroral cholangioscopy (POC) by using an ultra-slim endoscope provides direct visualization of the bile duct and allows for therapeutic intervention. Holmium laser lithotripsy can be effective for retained bile duct stones, but it requires direct visualization during the procedure for safe and effective fragmentation. Direct POC by using an ultra-slim endoscope may facilitate holmium laser lithotripsy.

OBJECTIVE

To evaluate the feasibility, success rates, and complications of holmium laser lithotripsy under direct POC by using an ultra-slim endoscope for retained bile duct stones.

DESIGN

Observational clinical feasibility study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 13 patients with retained bile duct stones whose treatment failed by a conventional lithotripsy method involving mechanical lithotripsy.

INTERVENTION

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope.

MAIN OUTCOME MEASUREMENTS

Success rate of complete stone removal and procedure-related complications.

RESULTS

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was successful in 11 of 13 patients (84.6%). Although direct POC was successful, holmium laser lithotripsy failed in 2 patients because of inaccurate targeting of the laser fiber to stones. There were no procedure-related complications except one case of mild pancreatitis.

LIMITATIONS

A small number of patients and no comparison with other lithotripsy systems.

CONCLUSION

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was feasible and can be a safe endoscopic management method for retained bile duct stones.

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.

Peroral cholangioscopy in the new millennium

Peroral cholangioscopy was first described in 1970s and has recently gained popularity. Peroral cholangioscopy is appealing to therapeutic endoscopists because a direct intraluminal view of the biliary duct system offers possibilities for diagnosis and interventions beyond that which other imaging or endoscopic modalities can provide. As the image quality of cholangioscopies improves, so too does their diagnostic capability, and as their durability and maneuverability increases, so too does their potential use for therapeutic applications. This editorial is intended to provide a brief review of recent developments in peroral cholangioscopy and current indications for its use.

Life-threatening hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy: report of a case

BACKGROUND

Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy.

CASE PRESENTATION

A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm.

CONCLUSIONS

Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.

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.

Endoscopic management of biliary ductal stones

Bile duct stone management has greatly changed in the past 2 decades. Open surgical techniques have mostly been replaced by transoral endoscopic techniques. Routine common bile duct stones can be managed by standard biliary endoscopic sphincterotomy and extraction. Various advanced transoral techniques can also manage most difficult ductal stones. In skilled centers, laparoscopic ductal stone management has assumed a back-up role.