Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Comparative Study of Endoscopic Treatment for Intrahepatic and Common Bile Duct Stones Using Peroral Cholangioscopy

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

Bouveret Syndrome: Etiology, Clinical Presentation, Differential Diagnosis, Complications, and Treatment Options

Bouveret syndrome is one of the complications of gallstone disease possibly fatal, which proposes the presence of a large stone obliterating the lumen of the duodenum or stomach because of the formation of a bilioenteric fistula. This review article, therefore, plans to review the causes, patient characteristics, diagnostic workup, associated conditions, and treatment of Bouveret syndrome. A literature search was also performed through scientific databases such as Scopus, Google Scholar, and PubMed concerning articles related to Bouveret syndrome written by different authors. The terms employed for the search were bilioduodenal fistula, Bouveret syndrome, gastric outlet obstruction, and gallstone ileus. Both case reports and systematic reviews that were written in the English language and published between the years 2000 and 2024 were considered. Finally, the review establishes the relevant concerns surrounding the diagnosis of Bouveret syndrome, focusing on the diagnosing issues. It emphasises the need for some specialities' involvement and focuses on the importance of endoscopic intervention. For patients, endoscopy remains the first line of treatment, while surgery is necessary in cases where conservative methods cannot be used. The article also focuses on new approaches to treating the conditions, such as percutaneous gallbladder stone dissolution. Latterly, further developments in minimally invasive surgery pertain to refining methods, including endoscopic removal and lithotripsy, to improve the survival rate of patients. Further investigation is required, especially regarding the administration schedule in relation to this disorder and goals that can reduce mortality and morbidity, especially in elderly patients with comorbid diseases.

Endoscopic Characterization of Giant Choledocholithiasis and Its Correlation With Primary Choledocholithiasis

INTRODUCTION

Gallstone disease is extremely prevalent in Western society, and the prevalence of common bile duct (CBD) stones with concomitant cholelithiasis increases significantly in the elderly. Different variants influence the treatment of this pathological entity, such as the origin of the stones, their location and quantity, comorbidities of the patient, impaction, and size of the lithos, the latter being an independent predictive factor. In most situations, choledocholithiasis can be resolved with endoscopic retrograde cholangiopancreatography (ERCP); however, in complex cases, such as giant choledocholithiasis (GC), advanced surgical, endoscopic, and percutaneous techniques are required to remove gallstones. The main objective was to determine if there is a correlation between GC and primary choledocholithiasis (PC). The secondary objective consisted of describing the endoscopic characterization of GC.

METHODS

 The present study is a cross-sectional and single-center study. The study population consisted of patients of the Institute for Social Security and Services for State Workers (ISSSTE by its acronym in Spanish) Regional Hospital, León, Guanajuato, belonging directly to this center or referred, who required medical attention by the General Surgery/Endoscopy Service with the diagnosis of choledocholithiasis, during the period between January 2017 and December 2022. The Kolmogorov-Smirnov test was used as the normality test. Quantitative variables were reported as mean and standard deviation if the data distribution was normal, in contrast with the expression of data in the median and interquartile range if an abnormal distribution was found. Moreover, the qualitative variables are reported in frequencies or percentages. The Chi-square test was performed as the independence test. The significance level was a 95% confidence interval (p-value 0.05). The effect size was calculated with the odds ratio (OR).

RESULTS

 Out of a total of 177 patients, 33 corresponded to PC (18.6%), and 144 belonged to the secondary choledocholithiasis (SC) group (81.4%). Likewise, regarding the dimensions of the lithos, 59 patients (33.3%) presented GC and 118 (66.7%) presented non-GC. Among the 59 patients with GC, 36 were female (61%) and 23 were male (39%). Regarding age, the distribution was as follows: mean 62 ± 12 years, with a minimum value of 29 and a maximum of 88 years. The non-parametric test used to determine the existence or not of a correlation between the variables was Pearson's Chi-square, whose value was 60.509, with a p < 0.001, demonstrating the presence of a correlation between PC and GC. The effect size was corroborated and defined with the OR, whose value was 39.6 (confidence interval (CI) 11.308-139.069).

CONCLUSIONS

 There is a significant correlation between GC and PC, and it was found that mechanical lithotripsy was the most performed initial extraction method for GC; furthermore, a higher rate of complete endoscopic resolution was found, as well as no complications related to the procedure, which contrasts with the literature. It would be interesting to use the information revealed in the present study as a landmark in future research in this regard.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND

The incidence of cholelithiasis has been on the rise in recent years, but the choice of procedure is controversial.

AIM

To investigate the efficacy of laparoscopic cholecystectomy (LC) combined with endoscopic papillary balloon dilation (EPBD) in patients with gallbladder stones (GS) with common bile duct stones (CBDS).

METHODS

The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC + EPBD group (n = 50) or an LC + endoscopic sphincterotomy (EST) group (n = 52) according to surgical methods. Surgery-related indexes, postoperative recovery, postoperative complications, and expression levels of inflammatory response indexes were compared between the two groups.

RESULTS

Total surgical time, stone free rate, rate of conversion to laparotomy, and successful stone extraction rate did not differ significantly between the LC + EPBD group and LC + EST group. Intraoperative hemorrhage, time to ambulation, and length of hospitalization in the LC + EPBD group were lower than those of the LC + EST group (P < 0.05). The rate of total complications of the two groups was 9.80% and 17.65%, respectively, and the difference was not statistically significant. No serious complications occurred in either group. At 48 h postoperatively, the expression levels of interleukin-6, tumor necrosis factor-α, high-sensitivity C-reactive protein, and procalcitonin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05). At 3 d postoperatively, the expression levels of aspartate transaminase, alanine transaminase, and total bilirubin were lower in the LC + EPBD group than in the LC + EST group (P < 0.05).

CONCLUSION

LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS, in which LC combined with EPBD is beneficial to shorten the patient's hospitalization time, reduce the magnitude of elevated inflammatory response indexes, and promote postoperative recovery.

Challenges in the management of acute lithiasic cholangitis due to a long-retained plastic biliary stent: A case report

BACKGROUND AND IMPORTANCE

This case report focuses on a rare cause of acute lithiasis cholangitis, which is residual choledocholithiasis on a plastic biliary stent that was placed nine years prior.

CASE PRESENTATION

An 87-year-old male, with a history of hypertension and previous surgery for gallstone disease including cholecystectomy and placement of a Kehr drain in 2006, was diagnosed with residual stones in 2008 and received a plastic biliary stent after endoscopic sphincterotomy. Lost to follow-up for nine years, he presented with acute lithiasis cholangitis characterized by fever, conjunctival jaundice, leukocytosis, CRP elevation, and biochemical signs of cholestasis. CT imaging revealed choledocholithiasis on the biliary stent. The patient underwent surgical intervention, during which a dilated bile duct was discovered, a complete tangential choledocotomy was performed, and the stent/stone complex along with additional choledocholithiasis was removed. A choledochoduodenal anastomosis was subsequently performed.

DISCUSSION

The use of plastic biliary stents can paradoxically lead to the formation of biliary stones, a condition termed "stentolith". Such scenarios emphasize the complications arising from prolonged stent presence, including bacterial proliferation and the consequent formation of calcium bilirubin stones. While endoscopic removal of these stent-stone complexes has been successful in a few cases, surgical intervention is often required due to the risks associated with endoscopic extraction, such as potential duodenal perforation. The choice of lithotripsy technique for endotherapy depends on availability and patient-specific factors.

CONCLUSION

This complication highlights the importance of patient education, meticulous record-keeping, and regular follow-up to prevent such outcomes.

Direct peroral cholangioscopy with laser lithotripsy in treating choledocholithiasis - single-institution experience

<b>Introduction:</b> Choledocholithiasis (CCL) is one of the most common serious health consequences of cholelithiasis. For years, evacuation of stones using endoscopic retrograde cholangiopancreatography (ERCP) has been the first-line treatment. In 10-15% of cases, gallstones cannot be removed using the above-mentioned method and auxiliary methods are necessary; these are so-called difficult gallstones. Surgical treatment is sometimes necessary. The European Society of Gastrointestinal Endoscopy (ESGE) has recommended the use of cholangioscopy, including direct peroral cholangioscopy (DPOC), as one of the main treatment methods since 2015.<b>Aim:</b> The following article aims to investigate the safety and efficacy of direct cholangioscopy with laser lithotripsy in the treatment of CCL.<b>Materials and methods:</b> The study was conducted at the Department of General and Transplant Surgery, Medical University of Lodz. From October 2022 to November 2023, 13 procedures of difficult gallstone evacuation from the bile duct were performed using the technique of direct cholangioscopy with laser lithotripsy.<b>Results:</b> Thirteen cases of difficult gallstones were retrospectively analyzed. The bile duct was intubated via the ampulla of Vater using direct cholangioscopy. The bile duct was cleared of gallstones using laser lithotripsy, followed by a Dormia basket or an extraction balloon to remove stone fragments. The procedure was performed successfully in all patients. No complications were observed.<b>Conclusions:</b> DPOC with laser lithotripsy seems to be an effective and safe method of clearing even very large gallstones from the bile duct. The relatively low price of tools and the resulting cost reduction may allow this procedure to become more popular.

Hepatolithiasis: Epidemiology, presentation, classification and management of a complex disease

The term hepatolithiasis describes the presence of biliary stones within the intrahepatic bile ducts, above the hilar confluence of the hepatic ducts. The disease is more prevalent in Asia, mainly owing to socioeconomic and dietary factors, as well as the prevalence of biliary parasites. In the last century, owing to migration, its global incidence has increased. The main pathophysiological mechanisms involve cholangitis, bile infection and biliary strictures, creating a self-sustaining cycle that perpetuates the disease, frequently characterised by recurrent episodes of bacterial infection referred to as syndrome of "recurrent pyogenic cholangitis". Furthermore, long-standing hepatolithiasis is a known risk factor for development of intrahepatic cholangiocarcinoma. Various classifications have aimed at providing useful insight of clinically relevant aspects and guidance for treatment. The management of symptomatic patients and those with complications can be complex, and relies upon a multidisciplinary team of hepatologists, endoscopists, interventional radiologists and hepatobiliary surgeons, with the main goal being to offer relief from the clinical presentations and prevent the development of more serious complications. This comprehensive review provides insight on various aspects of hepatolithiasis, with a focus on epidemiology, new evidence on pathophysiology, most important clinical aspects, different classification systems and contemporary management.

Risk factors analyses associated with postoperative infection in choledochoscopy for intrahepatic bile duct stones (IHDs): a single-center retrospective study in real-world setting

BACKGROUND

Choledochoscopy is a highly effective approach for managing intrahepatic bile duct stones (IHDs). However, postoperative infection is a common complication that significantly impacts treatment outcomes. Despite its clinical relevance, the risk factors associated with this procedure remain largely unexplored.

METHODS

This study focused on a consecutive cohort of patients who underwent choledochoscopy for IHDs at our institution between January 2016 and December 2022. The primary objective was to analyze the relationship between various clinical factors and postoperative infection, and to compare the postoperative infection of different choledochoscopic procedures.

RESULTS

The study cohort consisted of 126 patients, with 60 individuals (47.6%) experiencing postoperative infection. Notably, preoperative biliary obstruction (odds ratio [OR] 1.861; 95% confidence interval [CI] 1.314-8.699; p = 0.010) and operation time (OR 4.414; 95% CI 1.635-12.376; p = 0.004) were identified as risk factors for postoperative infection. Additionally, biliary tract infections (60.00%) were primarily responsible for postoperative infection, with Escherichia coli (47.22%) being the predominant bacterial strain identified in bile cultures. Furthermore, biliary tract obstruction (OR 4.563; 95% CI 1.554-13.401; p = 0.006) and body mass index (BMI) (OR 1.186; 95% CI 1.015-1.386; p = 0.031) were determined to be independent risk factors for postoperative biliary tract infection.

CONCLUSIONS

The occurrence of postoperative infection in patients undergoing choledochoscopy was primarily associated with the duration of the operation and the presence of preoperative biliary obstruction.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue

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

Adverse Events in Endoscopic Retrograde Cholangiopancreticography for Choledocholithiasis: A Holistic Perspective

Background and aims In this study, we aimed to investigate the frequency of adverse events (AEs) in patients undergoing endoscopic retrograde cholangiopancreticography (ERCP) for choledocholithiasis and the independent risk factors that may cause these conditions. We planned to evaluate all AEs including cardiopulmonary complications and the risk factors that may affect them holistically. Methods This study was designed as a retrospective cohort study conducted at a single tertiary center's gastroenterology clinic. The study included patients with naive papillae and undergoing ERCP for choledocholithiasis between May 2019 and June 2022. Risk factors that may lead to AEs were analyzed in terms of both patient-related factors and procedure-related factors. Patients with and without AEs after ERCP were compared. Results This study included 812 patients who underwent ERCP for choledocholithiasis. AE occurred in 149 (18.3%) of patients, and the most common complication was pancreatitis (n=112, 13.8%). In regression analysis, of the patient- and procedure-related factors, only difficult cannulation was a significant independent risk factor for AEs (odds ratio=3.85, 95% CI: 1.102-13.498, p=0.035). Conclusion This study showed that, of patient- and procedure-related factors, only difficult cannulation is an independent risk factor for ERCP-related AEs.

Risk factors for recurrence of common bile duct stones after surgical treatment and effect of ursodeoxycholic acid intervention

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal. Additionally, ursodeoxycholic acid (UDCA) can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concentration in bile. Despite these treatment options, there are still patients who experience stone recurrence.

AIM

To analyze the risk factors for choledocholithiasis recurrence after ERCP retrograde cholangiopancreatography and the effect of UDCA intervention.

METHODS

The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People's Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected. According to the post-ERCP treatment plan, 100 patients were classified into UDCA (n = 47) and control (n = 53) groups. We aimed to assess the clinical efficacy and rate of relapse in the two patient populations. We then collected information (basic demographic data, clinical characteristics, and serum biochemical indicators) and determined the factors contributing to relapse using logistic regression analysis. Our secondary goal was to determine the effects of UDCA on liver function after ERCP.

RESULTS

Compared to the control group, the UDCA group demonstrated a higher clinical effectiveness rate of 92.45% vs 78.72% (P < 0.05). No significant differences were observed in liver function indices, including total bilirubin, direct bilirubin, gamma-glutamyl transpeptidase, alanine aminotransferase, alkaline phosphatase, and aspartate aminotransferase, between the two groups before treatment. After treatment, all liver function indices were significantly reduced. Comparing the control vs UDCA groups, the UDCA group exhibited significantly lower levels of all indices (55.39 ± 6.53 vs 77.31 ± 8.52, 32.10 ± 4.62 vs 45.39 ± 5.69, 142.32 ± 14.21 vs 189.63 ± 16.87, 112.52 ± 14.25 vs 149.36 ± 15.36, 122.61 ± 16.00 vs 171.33 ± 22.09, 96.98 ± 10.44 vs 121.35 ± 11.57, respectively, all P < 0.05). The stone recurrence rate was lower in the UDCA group (13.21%) in contrast with the control group (44.68%). Periampullary diverticula (OR: 6.00, 95%CI: 1.69-21.30), maximum stone diameter (OR: 1.69, 95%CI: 1.01-2.85), stone quantity >3 (OR: 4.23, 95%CI: 1.17-15.26), and positive bile culture (OR: 7.61, 95%CI: 2.07-27.91) were independent factors that influenced the relapse of common bile duct stones after ERCP (P < 0.05). Furthermore, postoperative UDCA was identified as a preventive factor (OR: 0.07; 95%CI: 0.08-0.09).

CONCLUSION

The intervention effect of UDCA after ERCP for common bile duct stones is adequate, providing new research directions and references for the prevention and treatment of stone recurrence.

Cholangioscopy-guided tunneling and coaxial stenting of a large choledocholithiasis: a novel approach to mechanical lithotripsy

Video 1Cholangioscopy-guided tunneling and coaxial stenting of a large choledocholithiasis: a novel approach to mechanical lithotripsy. Fluoroscopy image of initial ERCP shows large filling defect (blue circle) and guidewire passing toward the common hepatic duct (black arrow).

Ultrasound-Guided Percutaneous Transhepatic Cholangioscopic Lithotripsy for the Treatment of Common Bile Duct Stones and Analysis of Risk Factors for Recurrence

BACKGROUND

As a minimally invasive treatment for common bile duct (CBD) stones, ultrasound-guided percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) is gaining attention and recognition from the medical community.

METHODS

A retrospective analysis was conducted on patients with CBD stones treated in our hospital from January 2016 to April 2022. Patients were divided into three groups: 77 treated with PTCSL, 93 with endoscopic retrograde cholangiopancreatography (ERCP), and 103 with laparoscopic common bile duct exploration (LCBDE). Their clinical data, perioperative indicators, and complications were analyzed comparatively. Then, risk factors for the post-PTCSL recurrence of CBD stones were analyzed by logistic regressions. Finally, the receiver operating characteristic curve was drawn.

RESULTS

All perioperative indicators of the PTCSL group were better than the LCBDE group (P < 0.001). The incidences of cholangitis, hemobilia, and incisional infection after surgery were lower in the PTCSL group than in the LCBDE group (P < 0.05). Pancreatitis, reflux esophagitis, and papillary stenosis occurred less frequently in the PTCSL group than in the ERCP group (P < 0.05). Logistic regression analysis indicated that gallstones and family history were independent risk factors. The AUC for recurrent CBD stones predicted by multi-indicators was 0.895 (95% CI 0.792-0.999, P < 0.001) with a sensitivity of 96.7% and specificity of 68.8%.

CONCLUSIONS

Ultrasound-guided PTCSL is a safe and effective treatment for CBD stones. Patients recovered quickly with fewer postoperative complications. It can be a first-line treatment for CBD stones. Gallstones and family history are independent risk factors for recurrent CBD stones, which provide a reference for clinicians in identifying the high-risk population needing close follow-up.

Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone removal or elective stone removal? A single-center retrospective study

BACKGROUND AND OBJECTIVE

For high-risk elderly patients with chronic diseases, endoscopic stone removal for large common bile duct stones is associated with a high risk of adverse events and incomplete stone removal. The aim of this study was to investigate whether the treatment strategy of short-term biliary plastic stent placement followed by elective endoscopic stone removal is more effective and safer than immediate endoscopic stone removal.

METHODS

The data of 262 high-risk elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones from 2017 to 2022 were retrospectively analyzed. The patients were divided into group A (immediate stone removal) and group B (stent drainage + elective stone removal). The baseline data of the 2 groups were matched 1:1 by propensity score matching. The stone clearance rate, ERCP procedure time, total hospital stay, and procedure-related adverse events were compared between the matched groups. In group B, stone size before and after stent placement, hospital stay, procedure time and adverse events of two ERCPs were compared.

RESULTS

A total of 57 pairs of patients were successfully matched between the 2 groups. The stone clearance rate in group B was higher than that in group A (89.5% vs. 75.3, P = 0.049). The total hospital stay in group B was longer than that in group A (11.86 ± 3.912 d vs. 19.14 ± 3.176 d, P<0.001). The total adverse event rate in group A was higher than that in group B (29.8% vs. 12.3%, P = 0.005). The incidence of cholangitis/cholecystitis after ERCP was significantly higher in group A than in group B (7.0% vs. 0.9% P = 0.029). There was no significant difference in the incidence of post-ERCP pancreatitis, bleeding, pneumonia, and cardio-cerebrovascular events between the 2 groups. There were no perforation cases in either group. After plastic biliary stent placement in group B, the stone size was significantly smaller than before stent placement (1.59 ± 0.544 cm vs. 1.95 ± 0.543 cm, P < 0.001), and there was no significant difference in the total adverse event incidence between the two ERCP procedures (18.8% vs. 10.9%, P = 0.214).

CONCLUSION

For high-risk elderly patients with large CBD stones, the treatment strategy involving temporary placement of plastic stent and elective endoscopic stone removal is safer and more effective than immediate stone removal.

The Role of Cholangioscopy in Biliary Diseases

Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.

Cholangioscopy-guided electrohydraulic lithotripsy versus laser lithotripsy for the treatment of choledocholithiasis: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Saline irrigation for reducing the recurrence of common bile duct stones after lithotripsy: a randomized controlled trial

Background

Mechanical lithotripsy produces stone fragments that are not easily detected by cholangiography and is a potential cause of recurrence of common bile duct stones (CBDS). This study aims to clarify whether 100 ml saline irrigation after mechanical lithotripsy reduces the recurrent rate of CBDS.

Methods

In this randomized controlled trial performed at the Surgical Endoscopy Center, the First Hospital of Lanzhou University between May 10, 2019, and Dec 31, 2020, patients undergoing endoscopic mechanical lithotripsy were randomly assigned to receive saline irrigation (study group) or no irrigation (control group). The saline irrigation was given 100 ml saline pulse irrigation after cholangiography showed no residual stones. Patients were followed up for at least 24 months after endoscopic stone removal to assess the recurrence of CBDS. This study was registered with ClinicalTrials.gov (NCT03937037).

Findings

During the median follow-up period of 35.6 months (interquartile range, 26.0-40.7), 43 of the 180 patients had stone recurrence (24%). The frequency of recurrence of CBD stones was 12.22% in the saline irrigation group and 35.56% in the control group, with a difference of 23.33% between the two groups (95% confidence interval [CI], 11.35%-35.32%, p < 0.001). Multivariable Cox proportional hazards analyses showed that constipation (hazard risk [HR] 2.42; 95% CI, 1.22-4.80, p = 0.012), periampullary diverticulum (PAD) (HR 3.06; 95% CI, 1.62-5.79, p < 0.001), and total to direct bilirubin ratio (HR 1.48; 95% CI, 1.21-1.81, p < 0.001) were independent risk factors for the recurrence of CBDS. Saline irrigation was the only preventive factor for the recurrence of CBDS (HR 0.22; 95% CI, 0.11-0.44, p < 0.001).

Interpretation

For patients with CBDS requiring mechanical lithotripsy, 100 ml saline irrigation effectively reduces the recurrent rate of CBDS after endoscopic stone removal.

Funding

This work was supported by National Natural Science Foundation of China (32160255); Natural Science Foundation of Gansu Province (22JR5RA898, 20JR10RA676); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043).

Comparison of Efficacy and Safety of Laparoscopic Holmium laser Lithotripsy and Laparoscopic Bile Duct Exploration for Bile Duct Stones: A Systematic Review and Meta-Analysis

BACKGROUND

Laparoscopic holmium laser lithotripsy (LHLL) has been used to treat bile duct stones with unclear outcomes. A meta-analysis was conducted to investigate the LHLL and laparoscopic bile duct exploration (LBDE) efficacy and safety in treating bile duct stones.

METHODS

The correlational studies were searched databases, such as PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang, and VIP, to identify eligible studies from inception to July 2022. The dichotomous and continuous outcomes were evaluated using odds ratio (OR), risk difference (RD) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Stata 15.0 and Review Manager 5.3 software helped in data analyses.

RESULTS

A total of 23 studies with 1,890 patients, primarily from China, were included. The results indicated that operation time (WMD = - 26.94; 95% CI:(- 34.30, - 19.58); P < 0.00001), estimated blood loss (WMD = - 17.97; 95% CI: (- 22.94, - 13.00); P = 0.002), rate of residual stone (OR = 0.15, 95%CI: (0.10, 0.23); P < 0.00001), length of hospital stay (WMD = - 2.88; 95% CI:(- 3.80, - 1.96); P < 0.00001) and time to bowel function recovery (WMD = - 0.59; 95% CI: (- 0.76, - 0.41); P < 0.00001) had statistically significant differences between the two groups. In postoperative complications, biliary leakage (RD = -0.03; 95% CI: (- 0.05, -0.00); P = 0.02), infection (RD = - 0.06; 95% CI: (- 0.09,- 0.03); P < 0.00001) and Hepatic injury (RD = - 0.06; 95% CI: (- 0.11, - 0.01); P = 0.02) revealed statistically significant differences. However, no significant differences were observed in biliary damage (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.06) and hemobilia (RD = - 0.03; 95% CI: (- 0.06, 0.00); P = 0.08).

CONCLUSION

The current meta-analysis indicated that LHLL could be more effective and safer than LBDC. However, these results should be confirmed with a larger sample size and rigorously designed randomized controlled trials.

Role of choledochotomy after mechanical lithotripsy-related adverse event in endoscopic retrograde cholangiopancreatography

In case of rupture of the mechanical lithotripter's traction wires during an ERCP, we suggest performing a choledochotomy to remove the stone, and remove the closed Dormia basket through the mouth.

The Usefulness of Peroral Cholangioscopy for Intrahepatic Stones

Peroral cholangioscopy (POCS) is believed to be effective in treating intrahepatic stones; however, reports on its efficacy are few. We reviewed the results of intrahepatic stones treated with fluoroscopic guidance or POCS. This study included 26 patients who underwent endoscopic treatment for intrahepatic stones at our institution between January 2017 and December 2021. We retrospectively evaluated the procedure time and adverse events in the first session and the rate of complete stone removal. Complete stone removal was achieved in 92% (24/26); POCS was required in 16 of 26 (62%) procedures and the complete stone removal was achieved in 15 of 16 (94%) of these procedures. The POCS group had a significantly longer procedure time than the fluoroscopy group. Cholangitis incidence was high; however, no difference was noted between patients with and without POCS, and all cases were mild and treated conservatively. Endoscopic treatment for intrahepatic stones may lead to an increase in the incidence of cholangitis, requires specialized devices such as a cholangioscope, and should be performed in an established institution by experienced staff. POCS is useful for intrahepatic stones formed upstream of the stenosis and intrahepatic stones piled in the bile duct.

Rare post-endoscopic retrograde cholangiopancreatography complications: Can we avoid them?

Regarded as a minimally invasive procedure, endoscopic retrograde cholangiopancreatography (ERCP) is commonly used to manage various pancreaticobiliary disorders. The rate of complications is low and starts from 4% for diagnostic interventions. The group of most frequent negative outcomes is commonly known and includes pancreatitis, cholecystitis, and hemorrhage. Rare adverse effects occur occasionally but carry a significant risk of unexpected and potentially dangerous results. In some cases, including splenic injury, the knowledge of pre-existing conditions might be helpful in avoiding the unwanted outcome, while in others, the risk factors are not clearly defined. Such situations demand increased caution in the post-ERCP period. The appearance of abdominal pain, peritoneal symptoms, or instability of the patient’s hemodynamic condition should alert the physician and lead to further investigation of the possible causes. The diagnostic process usually involves imaging tests. The implementation of the appropriate treatment should be immediate, as many of the rare complications carry the risk of dangerous, even potentially lethal, results.

[Endoscopically non-removable stones of the common bile duct]

OBJECTIVE

To evaluate the effectiveness of long-term biliary stenting in the treatment of endoscopically intractable common bile duct stones.

MATERIAL AND METHODS

The study enrolled 247 patients with endoscopically non-removable bile duct calculi («difficult» choledocholithiasis) divided into two comparable groups. The main group included 129 patients who underwent biliary stenting with original stents with a nanocarbon inert coating (RF patent No. 84226), including those with inclusion of silver nanoclusters (RF patent No. 129397). The control group included 118 patients who underwent all methods of surgical treatment of choledocholithiasis, while biliary stents with original nanocarbon silver-containing inert coating were excluded. The vast majority of patients were women of advanced age (mean 66.8±4.7 and 66.3±5.6, max 89 and 90, min 32 and 37 years, respectively).

RESULTS

In the control group, all patients underwent endoscopic transpapillary interventions as soon as possible. We could not extract common bile duct stones via endoscopic approach in 56.8% of cases. These patients underwent open or laparoscopic choledocholithotomy with lithoextraction. Complications occurred in 28.5% of cases. Mortality rate was 4.2%. Standard stenting of common bile duct was performed in 28.8% of cases. At the same time, stent dysfunction followed by relapse of obstructive jaundice occurred in 27.1% of patients within 3-3.5 months. Of these, 16 patients (13.5%) underwent stent removal and lithoextraction. Re-stenting was performed in 18 patients (15.3%). Moreover, shock wave lithotripsy with subsequent removal of common bile duct calculi was performed in 8 (6.8%) of these patients the next day. In the main group, original biliary plastic stents with nanocarbon silver-containing inert coating were implanted in all patients. Under permanent therapy with ursodeoxycholic acid drugs, we observed significant shrinkage of calculi to 11.8±1.8 mm and decrease in their density. This made it possible to carry out successful extraction of calculi in 81 patients (62.8%) after 6±0.3 months. Shock wave lithotripsy was performed in 36 (27.9%) cases. This procedure was successful and allowed final lithoextraction in 28 patients (21.7%). Re-stenting was performed in 15 (11.6%) cases, laparotomy - in 5 (3.9%) patients. Mortality rate was 0.78%.

CONCLUSION

Our data allow us to discuss high efficiency of long-term bile duct stenting with plastic stents with nanocarbon silver-containing inert coating in complex treatment of choledocholithiasis. This approach ensures acceptable incidence of undesirable complications and mortality. This situation undoubtedly dictates the need for further larger prospective studies.