Current strategies for the endoscopic management of difficult-to-treat bile duct stones in Japan

Addition of Mechanical Lithotripsy to Endoscopic Papillary Large Balloon Dilation in Patients with Difficult Common Bile Duct Stones: A Retrospective Single-Center Study

Introduction: This study aimed to compare the treatment outcomes of endoscopic papillary large-balloon dilation (EPLBD) with and without mechanical lithotripsy (ML) in removing difficult common bile duct stones. Methods: Patients with difficult common bile duct stones treated with EPLBD, with or without ML, at the Eastern Chiba Medical Center between April 2014 and March 2020, were retrospectively evaluated. The rates of cumulative recurrence and complications were compared between the two groups. Results: Overall, 122 patients (n = 44, EPLBD + ML and n = 78, EPLBD) treated by 12 gastroenterologists were included. Patients in the EPLBD + ML group were older (85 years versus 81.5 years) and had larger maximum stone diameter (15 mm versus 12.5 mm) than those in the EPLBD group. Compared with the EPLBD group, the EPLBD + ML group required more endoscopic retrograde cholangiopancreatography (ERCP) procedures (≥2) (86% versus 67%) and longer total ERCP time after reaching the papilla (78.5 minutes versus 25 minutes). Complication rates were not significantly different (9.1% versus 12.8%); however, the cumulative recurrence rates were higher in the EPLBD + ML group than in the EPLBD group (69.4% versus 23.5% at 4 years). Conclusion: Although there were no differences in complication rates, the long-term recurrence rate was higher in the EPLBD + ML group than in the EPLBD group. This study emphasizes the added burden imposed by performing ML during ERCP and suggests that by appropriate case selection, it is possible to treat cases of difficult biliary stones using EPLBD without ML.

Comparison of radiation exposure between endoscopic ultrasound-guided drainage and transpapillary drainage by endoscopic retrograde cholangiopancreatography for pancreatobiliary diseases

OBJECTIVES

The transpapillary drainage by endoscopic retrograde cholangiopancreatography (ERCP-D) cannot be performed without fluoroscopy, and there are many situations in which fluoroscopy is required even in endoscopic ultrasound-guided drainage (EUS-D). Previous studies have compared the efficacy, but not the radiation exposure of EUS-D and ERCP-D. While radiation exposure in ERCP-D has been previously evaluated, there is a paucity of information regarding radiation doses in EUS-D. This study aimed to assess radiation exposure in EUS-D compared with that in ERCP-D.

METHODS

This retrospective single-center cohort study included consecutive patients who underwent EUS-D and ERCP-D between October 2017 and March 2019. The air kerma (AK, mGy), kerma-area product (KAP, Gycm² ), fluoroscopy time (FT, min), and procedure time (PT, min) were assessed. The invasive probability weighting method was used to qualify the comparisons.

RESULTS

We enrolled 372 and 105 patients who underwent ERCP-D and EUS-D, respectively. The mean AK, KAP, and FT in the EUS-D group were higher by 53%, 28%, and 27%, respectively, than those in the ERCP-D group, whereas PT was shorter by approximately 11% (AK, 135.0 vs. 88.4; KAP, 28.1 vs. 21.9; FT, 20.4 vs. 16.0; PT, 38.7 vs. 43.5). The sub-analysis limited to biliary drainage cases showed the same trend (AK, 128.3 vs. 90.9; KAP, 27.0 vs. 22.2; FT, 16.4 vs. 16.1; PT, 32.5 vs. 44.4).

CONCLUSIONS

This is the first study to assess radiation exposure in EUS-D compared with that in ERCP-D. Radiation exposure was significantly higher in EUS-D than in ERCP-D, despite the shorter procedure time.

Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy

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

Single-operator peroral cholangioscope in treating difficult biliary stones: A systematic review and meta-analysis

BACKGROUND AND AIM

Current evidence supporting the utility of single-operator peroral cholangioscope (SOPOC) in the management of difficult bile duct stones is limited. We conducted the present systematic review and meta-analysis to evaluate the efficacy and safety of SOPOC in treating difficult bile duct stones.

METHODS

We searched studies up to April 2018, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. Quality assessment of the studies was completed with the Newcastle-Ottawa Scale. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverse events. We calculated the pooled estimates with random-effects models. Potential publication bias was assessed.

RESULTS

Twenty-four studies involving 2786 patients met the inclusion criteria. Pooled proportion of patients with complete stone clearance was 94.3% (95% confidence interval [95% CI]: 90.2-97.5%). Single-session stone clearance was achieved in 71.1% (95% CI: 62.1-79.5%) of the pooled patients. Pooled number of sessions needed for stone clearance was 1.26 (95% CI: 1.17-1.34%). Pooled adverse event rate was 6.1% (95% CI: 3.8-8.7%). Potential publication bias was detected but had no significant influence on the results.

CONCLUSIONS

Single-operator peroral cholangioscope is an effective and safe treatment for difficult bile duct stones when conventional methods have failed. More randomized controlled trials are warranted to confirm the results.