Transpapillary Cholangioscopy–Directed Lithotripsy in Patients With Difficult Bile Duct Stones (original) (raw)
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GE - Portuguese Journal of Gastroenterology, 2018
Background and Aims: Endoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones. Methods: This is a prospective clinical study – conducted at two affiliated university hospitals – of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated t...
Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones
Gastrointestinal Endoscopy, 2004
Background: Mechanical lithotripsy is used to break large bile duct stones. This study investigated the predictors of unsuccessful mechanical lithotripsy. Methods: Consecutive patients with bile duct stones underwent endoscopic retrograde cholangiography, sphincterotomy, and basket removal of stones. Mechanical lithotripsy was performed for stones of large size (>15 mm diameter) that precluded extraction intact. Success was defined as complete clearance of the duct. Various predictive factors, including size and number of stones, stone impaction, serum bilirubin, presence of cholangitis, and bile duct diameter were analyzed in relation to the success or failure of lithotripsy. Results: A total of 669 patients underwent endoscopic retrograde cholangiography for suspected choledocholithiasis, which was found in 401 patients. Of the latter patients, 87 had large stones that required mechanical lithotripsy. Lithotripsy was successful in 69 (79%) patients. Impaction of the stone(s) in the bile duct was the only significant factor that predicted failure of lithotripsy and consequent failure of bile duct clearance. Other factors, including stone size, were not significant. Conclusions: Mechanical lithotripsy is successful in about 79% of patients with large bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is stone impaction in the bile duct.
Journal of Translational Internal Medicine, 2020
Background and Objective: Extracorporeal shock wave lithotripsy (ESWL) for common bile duct (CBD) stones has been used in the past, but experience is limited. We report our experience of ESWL in the management of difficult CBD stones. Methods: Patients with difficult-to-retrieve CBD stones were enrolled and underwent ESWL. Fluoroscopy is used to target the stones after injection of contrast via nasobiliary drain. CBD clearance was the main outcome of the study. Results: Eighty-three patients were included (mean age 50.5 ± 14.5 years); these patients were mainly females (43; 51.8%). Large stones >15 mm were noted in 64 (77.1%), CBD stricture in 22 (26.5%) and incarcerated stone in 8 (9.6%) patients. Patients needed 2.1 ± 1.2 sessions of lithotripsy and 4266 ± 1881 shock waves per session. In 75 (90.3%) patients, the fragments were extracted endoscopically after ESWL, while spontaneous passage was observed in 8 (9.6%). Total CBD clearance was achieved in 67 (80.6%) patients, partial clearance in 5 (6%) and no response in 11 (13.2%). Failure of the treatment was observed in large stone with size ≥2 cm (P = 0.021), incarcerated stone (P = 0.020) and pre-endoscopic retrograde cholangiopancreatography cholangitis (P = 0.047). Conclusion: ESWL is a noninvasive, safe and effective therapeutic alternative to electrohydraulic lithotripsy and surgical exploration for difficult biliary stones.
Management of Common Bile Duct Stones: A Comprehensive Review
Biomedical Sciences, 2020
Bile duct stones (BDS) are usually secondary to gallstones but may be found primarily in biliary system, although the percentage is minimal. They are usually suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis, the latter can be life-threatening in some patients. Abnormalities in the liver function tests especially the elevated direct bilirubin and alkaline phosphatase indirectly raise the suspicion. The majority of BDS can be diagnosed by Transabdominal Ultrasound, but in some cases further imaging such as, Computed Tomography, Endoscopic Ultrasound or Magnetic Resonance Cholangiography are employed prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following Endoscopic Retrograde Cholangiography (ERC) + sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC + pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. Despite all the minimally invasive procedures the role of open surgery for the removal of difficult or impacted stones cannot be completely forgotten. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.
Saudi Journal of Gastroenterology, 2018
Introduction: Endoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. Methods: A retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). Results: One hundred eighty one patients (mean age 64 years and sex ratio M/W ¼ 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n ¼ 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3-40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272-0.979], an intra-diverticular papilla OR 0.179 [0.035-0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068-0.385] and a stenosis of the common bile duct OR 0.068 [0.008-0.605]. The success rate of the second line treatment was 73%. Conclusion: Endoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.
Journal of Gastrointestinal and Liver Diseases, 2019
Background & Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence. Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed. Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence or suspicion of recurrent choledocholithiasis. Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.