Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts

BACKGROUND

Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.

AIM

To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.

METHODS

Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications.

RESULTS

Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively).

CONCLUSION

Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

Choledochal Cyst or Benign Biliary Dilation: Is Resection Always Necessary?

BACKGROUND

Choledochal cysts (CC) are often diagnosed during the first few decades of life, when, due to the risk of malignancy, resection is advised. With an increasing number of patients undergoing abdominal imaging, many older patients have recently been radiographically diagnosed with biliary duct enlargement that meets the criteria of choledochal cysts. The management in these patients is less well defined, but resection is often recommended as it is for younger patients. We sought to better understand the significance of these biliary duct anomalies in adults.

METHODS

We retrospectively reviewed all patients 18 years and older at our institution, who were given a radiographic diagnosis of choledochal cyst during the interval 2006-2019. Demographics, comorbidities, complications, readmissions, and follow-up imaging were evaluated.

RESULTS

We identified 22 patients, of whom 40.9% (n = 9) underwent an operation. The remainder was observed. Median duct size was 15 mm (range 2-25 mm). There were no significant differences in demographics between the two cohorts. Of those who underwent resection, none had evidence of high-grade dysplasia or invasive carcinoma upon final pathology. However, 33.3% (n = 3) had subsequent readmissions for complications, including post-operative nausea and vomiting, cholangitis, and anastomotic stenoses that required stenting. In the observation group, there was no obvious growth of the cysts or development of worrisome features to suggest malignant degeneration (median follow-up = 68 months).

CONCLUSION

A radiographic diagnosis of choledochal cyst in older adults is likely a different entity than those diagnosed in childhood. Close surveillance of these biliary duct anomalies in older adults may be a better option than resection and reconstruction with the associated risks of long-term morbidity.

Incidental biliary dilation in the era of the opiate epidemic: High prevalence of biliary dilation in opiate users evaluated in the Emergency Department

BACKGROUND

Biliary dilation is frequently related to obstruction; however, non-obstructive factors such as age and previous cholecystectomy have also been reported. In the past two decades there has been a dramatic increase in opiate use/dependence and utilization of cross-sectional abdominal imaging, with increased detection of biliary dilation, particularly in patients who use opiates.

AIM

To evaluate associations between opiate use, age, cholecystectomy status, ethnicity, gender, and body mass index utilizing our institution’s integrated informatics platform.

METHODS

One thousand six hundred and eighty-five patients (20% sample) presenting to our Emergency Department for all causes over a 5-year period (2011-2016) who had undergone cross-sectional abdominal imaging and had normal total bilirubin were included and analyzed.

RESULTS

Common bile duct (CBD) diameter was significantly higher in opiate users compared to non-opiate users (8.67 mm vs 7.24 mm, P < 0.001) and in patients with a history of cholecystectomy compared to those with an intact gallbladder (8.98 vs 6.72, P < 0.001). For patients with an intact gallbladder who did not use opiates (n = 432), increasing age did not predict CBD diameter (r² = 0.159, P = 0.873). Height weakly predicted CBD diameter (r² = 0.561, P = 0.018), but weight, body mass index, ethnicity and gender did not.

CONCLUSION

Opiate use and a history of cholecystectomy are associated with CBD dilation in the absence of an obstructive process. Age alone is not associated with increased CBD diameter. These findings suggest that factors such as opiate use and history of cholecystectomy may underlie the previously-reported association of advancing age with increased CBD diameter. Further prospective study is warranted.

The Use of Endoscopic Ultrasound in the Evaluation of Unexplained Biliary Dilation

Isolated biliary dilation, as an incidental diagnosis, is increasing owing to an increase in the use of noninvasive abdominal imaging and poses a diagnostic challenge to physicians especially when further noninvasive diagnostic testing fails to reveal an etiology. This article reviews available data describing the natural history of this clinical scenario and the impact of endoscopic ultrasound examination in the evaluation of unexplained dilation of the common bile duct.

A pilot proof-of-concept study of a modified device for one-step endoscopic ultrasound-guided biliary drainage in a new experimental biliary dilatation animal model

AIM: To evaluate the technical feasibility of a modified tapered metal tip and low profile introducer for one-step endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) in a new experimental biliary dilatation porcine model.

METHODS: A novel dedicated device for one-step EUS-guided biliary drainage system (DEUS) introducer has size 3F tapered catheter with size 4F metal tip for simple puncture of the intestinal wall and liver parenchyma without graded dilation. A self-expandable metal stent, consisting of both uncovered and nitinol-covered portions, was preloaded into DEUS introducer. After establishment of a biliary dilatation model using endoscopic hemoclips or band ligation with argon plasma coagulation in 9 mini-pigs, EUS-BD using a DEUS was performed following 19-G needle puncture without the use of fistula dilation devices.

RESULTS: One-step EUS-BD was technically successful in seven pigs [7/9 (77.8%) as intention to treat] without the aid of devices for fistula dilation from the high body of stomach or far distal esophagus to the intrahepatic (n = 2) or common hepatic (n = 5) duct. Primary technical failure occurred in two cases that did not show adequate biliary dilatation. In seven pigs with a successful bile duct dilatation, the technical success rate was 100% (7/7 as per protocol). Median procedure time from confirmation of the dilated bile duct to successful placement of a metallic stent was 10 min (IQR; 8.9-18.1). There were no immediate procedure-related complications.

CONCLUSION: Modified tapered metal tip and low profile introducer may be technically feasible for one-step EUS-BD in experimental porcine model.