Predictive factors for the necessity of peroral cholangioscopy-guided lithotripsy in the endoscopic treatment of cystic duct confluence stones: a retrospective study in Japan.

Long-term Results of Extracorporeal Shockwave Lithotripsy and Endoscopic Therapy for Pancreatic Stones

BACKGROUND : Endoscopic papillary large balloon dilation (EPLBD) has been increasingly used for the management of large common bile duct (CBD) stones. Although EPLBD is often preceded by endoscopic sphincterotomy (EST), EPLBD alone without EST has been increasingly reported as an alternative to EST for large CBD stones. METHODS : This multicenter randomized trial was conducted at 19 Japanese institutions to compare the efficacy and safety of EPLBD alone versus EST for the removal of large (≥ 10 mm) CBD stones. The primary end point was complete stone removal in a single session. The secondary end points included: overall complete stone removal, lithotripsy use, procedure time, adverse events, and cost. RESULTS: 171 patients with large CBD stones were included in the analysis. The rate of single-session complete stone removal was significantly higher in the EPLBD-alone group than in the EST group (90.7 % vs. 78.8 %; P = 0.04). Lithotripsy use was significantly less frequent in the EPLBD group than in the EST group (30.2 % vs. 48.2 %; P = 0.02). The rates of early adverse events were comparable between the two groups: rates of overall adverse events were 9.3 % vs. 9.4 % and of pancreatitis were 4.7 % vs. 5.9 % in the EPLBD and EST groups, respectively. The procedure costs were $1442 vs. $1661 in the EPLBD and EST groups, respectively (P = 0.12). CONCLUSION : EPLBD without EST for the endoscopic treatment of large CBD stones achieved a significantly higher rate of complete stone removal in a single session compared with EST, without increasing adverse events.

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.

In order to evaluate the effectiveness of various methods we applied to decrease the influence of periampullary diverticula (PAD) on the success rate and complications of endoscopic retrograde cholangiopancreatography (ERCP) in the treatment of common bile duct (CBD) stones, we enrolled patients with CBD stones who had been treated by ERCP in our hospital between January 2015 and December 2018. According to the presence of PAD, the patients were divided into a PAD group and a non-PAD group. The rate of complete stone removal in the first session, the rate of overall stone removal, the frequency of application of mechanical lithotripsy, and procedure-related complications, including bleeding, hyperamylasemia, pancreatitis, perforation, and infection of biliary tract were recorded. A total of 183 cases, including 72 cases in the PAD group and 111 cases in the non-PAD group were enrolled. There was no statistical difference between the two groups regarding gender (P = 0.354). However, regarding age, there was a statistical difference (P = 0.002), and the incidence of PAD increased with age. There were 5 (6.9%) cases in the PAD group and 14 (12.6%) cases in the non-PAD group where mechanical lithotripsy was applied. There were 59 (81.9%) cases in the PAD group and 102 (91.9%) cases in the non-PAD group where there was complete removal of CBD stones in the first session, and there were 68 (94.4%) cases in the PAD group and 107 (96.4%) cases in the non-PAD group where there was complete removal of all stones. In the PAD group, there were 0 cases (0%) with gastrointestinal bleeding, 0 cases (0%) with gastrointestinal perforation, 13 cases (18.1%) with post-ERCP hyperamylasemia, 3 cases (4.2%) with post-ERCP pancreatitis, and 4 cases (5.6%) with biliary tract infection. In the non-PAD group, 1 case (0.9%) had gastrointestinal bleeding, 0 cases had gastrointestinal perforation, 18 cases (16.2%) had post-ERCP hyperamylasemia, 5 cases (4.5%) had post-ERCP pancreatitis, and 11 cases (9.9%) had biliary tract infection. This retrospective study showed that there was a statistical difference between the two groups regarding complete removal of CBD stones in the first session and application of mechanical lithotripsy (both P < 0.05), but no statistical difference according to the rates of overall stone removal and the complications (P > 0.05), which means that we can reduce the influence of PAD on ERCP for treatment of common bile duct stones.

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

Objective Recently, a new digital peroral cholangioscopy (POCS) system, the SpyGlass DS (SpyDS), has been used for POCS-guided lithotripsy for difficult bile duct stones (DBDSs). The aim of this retrospective study was to compare the efficacy of SpyDS-guided electrohydraulic lithotripsy (EHL) for DBDS with that of a conventional digital cholangioscope. Methods Seventeen consecutive patients who had undergone POCS-guided EHL for DBDS with the SpyDS between October 2015 and January 2019 were enrolled in this study group (SpyDS group) using a prospectively maintained database. Fifteen other consecutive patients who had undergone POCS-guided EHL with a conventional digital cholangioscope (CHF-B260) just prior to the introduction of the SpyDS between December 2006 and September 2015 were analyzed as a control group (CHF group). The main outcome measurement was the total procedure time to complete stone removal. Results The rate of complete stone removal was 100% for both groups. The mean total procedure time for the SpyDS group was significantly shorter than that for the CHF group (67±30 minutes vs. 107±64 minutes, p=0.038). The mean number of endoscopic sessions for the SpyDS group was significantly lower than that for the CHF group (1.35±0.49 vs. 2.00±0.85, p=0.037). There were no significant differences in the rate of adverse events between the two groups. Conclusion The SpyDS appears useful for decreasing the procedure time and number of endoscopic sessions for complete stone removal in POCS-guided EHL for DBDS compared with a conventional digital cholangioscope.

In clinical practice, standard endoscopic treatment of biliary stones fails in up to 10% of patients, and more invasive procedures such as percutaneous trans-hepatic interventions or surgery might become necessary. The aim of this multicenter retrospective study, based on prospectively-collected data, was to evaluate both the efficacy and the safety of digital-single operator cholangioscopy (D-SOC) to treat difficult biliary stones in cases with a previous failure of conventional endoscopic methods. Only patients with a previous failure of endoscopic standard treatment and a D-SOC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone clearance rate per procedure and per patient. Out of 1258 ERCP performed at our centers, 31 cholangioscopes in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL. A complete biliary stone removal was achieved in 67.7% (21/31) of all procedures including initial and repeated examinations, while in 35.4% (11/31) of all procedures an incomplete removal was accomplished of which 36.3% had a partial stone removal. In 22 procedures EHL was adopted as techniques to fragment and remove biliary stones, while in 9 procedures LL was used. In both the techniques, the complete stone removal rate and the incomplete stone removal rate were similar (75% vs. 77.7%, P>0.05). Furthermore, the success rate of digital D-SOC to treat difficult biliary stones was assessed per patient: overall, 100% of patients with difficult biliary stones were successfully treated using D-SOC. Only one patient experienced mild cholangitis classified ad mild adverse event following ASGE (American Society of Gastrointestinal Endoscopy) lexicon. Our data indicate that digital D-SOC assisted biliary stone treatment is highly efficient for the treatment of difficult biliary stones even in such patients in whom previous conventional endoscopic methods to treat biliary stones have failed. Therefore, D-SOC might be considered the new standard of care for these patients, being both, effective and safe.

Endoscopic sphincterotomy (EST) is a standard treatment for common bile duct (CBD) stones. Endoscopic sphincterotomy combined with endoscopic papillary large balloon dilation (EST-EPLBD) is an effective treatment for difficult CBD stones. This study aims to evaluate and compare the effectiveness and adverse effects of EST-EPLBD and EST in treating large CBD stones. We retrospectively analyzed the data of 85 patients with large CBD stones who underwent either EST or EST-EPLBD, resulting in successful CBD stone extraction from January 2018 to June 2022. Propensity score inverse weighting was performed to reduce the possible bias in baseline characteristics between the two treatment groups. The success rate of complete stone removal in the first session, mechanical lithotripsy use, and adverse events were analyzed by multivariable risk regression analysis. The rate of complete stone removal in one session of the EST-EPLBD group was higher than that of the EST group at 28.78% (95% confidence interval [CI] 4.43, 50.1; p = 0.003). Mechanical lithotripsy use was decreased in the EST-EPLBD group by 25.81% (95% CI 42.33,9.28; p = 0.002). However, the incidence of adverse events is comparable. EST-EPLBD may be utilized in the treatment of CBD stones that exceed a diameter of 10 mm. The EST-EPLBD increased the rate of complete stone removal in a single session and reduced the need for mechanical lithotripsy. Conversely, the incidence rate of adverse events is similar.

Management of bile duct stones (BDSs) in patients with surgically altered anatomies (SAAs) remains challenging. An endoscopic ultrasound-guided antegrade (EUS-AG) procedure and double-balloon enteroscopy-assisted endoscopic retrograde cholangiography (DB-ERC) have been used to remove BDSs from patients with SAAs. However, few comparative data have been reported. Therefore, we compared the efficacy and safety of the techniques. This was a single-center retrospective study. Patients with SAA who underwent the EUS-AG procedure or DB-ERC to remove intra- or extra-BDSs between November 2010 and March 2020 were included. The primary outcome was the technical success rate, defined as stent insertion or stone removal during the initial session. The secondary outcomes were the procedure time, incidence of adverse events (AEs), and complete stone removal rate. Of the 54 patients enrolled, 23 underwent the EUS-AG procedure and 31 DB-ERC. The technical success rates of EUS-AG and DB-ERC were 87.0% and 64.5%, respectively (P=0.11). The procedure time was significantly shorter in the EUS-AG group than in the DB-ERC group (51.9±15.4 vs 72.6±32.2min; P=0.01), and the early AE rates were 26.1% and 12.9%, respectively (P=0.71). The complete stone removal rates in patients who underwent previous stone removal were 94.1% in the EUS-AG group and 85.7% in the DB-ERC group (P=0.61). The EUS-AG afforded technical success and complete stone removal rates comparable with those of DB-ERC, but the former procedure was shorter. The AE rate was acceptable.

Therapeutic Endoscopic Retrograde Cholangiopancreaticography (ERCP) for Bile Duct Stones in Patients with a Prior Billroth II Gastrectomy

To evaluate the safety and efficacy of endoscopic papillary large balloon dilatation (EPLBD) without endoscopic sphincterotomy in a prospective study. From July 2011 to August 2013, we performed EPLBD on 41 patients with naïve papillae prospectively. For sphincteroplasty of EPLBD, endoscopic sphincterotomy (EST) was not performed, and balloon diameter selection was based on the distal common bile duct diameter. The balloon was inflated to the desired pressure. If the balloon waist did not disappear, and the desired pressure was satisfied, we judged the dilatation as complete. We used a retrieval balloon catheter or mechanical lithotripter (ML) to remove stones and assessed the rates of complete stone removal, number of sessions, use of ML and adverse events. Furthermore, we compared the presence or absence of balloon waist disappearance with clinical characteristics and endoscopic outcome. The mean diameters of the distal and maximum common bile duct were 13.5 ± 2.4 mm and 16.4 ± 3.1 mm, respectively. The mean maximum transverse-diameter of the stones was 13.4 ± 3.4 mm, and the mean number of stones was 3.0 ± 2.4. Complete stone removal was achieved in 97.5% (40/41) of cases, and ML was used in 12.2% (5/41) of cases. The mean number of sessions required was 1.2 ± 0.62. Pancreatitis developed in two patients and perforation in one. The rate of balloon waist disappearance was 73.1% (30/41). No significant differences were noted in procedure time, rate of complete stone removal (100% vs 100%), number of sessions (1.1 vs 1.3, P = 0.22), application of ML (13% vs 9%, P = 0.71), or occurrence of pancreatitis (3.3% vs 9.1%, P = 0.45) between cases with and without balloon waist disappearance. EST before sphincteroplasty may be unnecessary in EPLBD. Further investigations are needed to verify the relationship between the presence or absence of balloon waist disappearance.

Endoscopic treatment of common bile duct (CBD) stones involves the use of basket or balloon catheters; however, what is the appropriate device remains controversial. In this study we aimed to prospectively evaluate the usefulness of a novel 8-wire helical basket (8WB) catheter made of Nitinol for the removal of CBD stones ≤10 mm. We conducted a multicenter prospective trial. Patients with CBD stones ≤10 mm were enrolled. The primary endpoint was the rate of complete stone removal within 10 min using the 8WB. The number of cases was determined using a previous study of stone removal by a conventional basket catheter as a historical control. A total of 155 patients were enrolled and 139 were ultimately included in the analysis. Patients with a single stone were the most common (84 cases, 60.4%), with a median maximum stone diameter of 5 mm. The median stone removal time using the 8WB was 6 min. The complete stone removal rate was 95.0% (132/139). Adverse events were observed in 14 patients (10.1%). The novel 8WB catheter is useful in the treatment of CBD stones ≤10 mm, presenting a high complete stone removal rate in this study. jRCT1032200324.

ERCP using balloon-assisted endoscopes versus EUS-guided treatment for common bile duct stones in Roux-en-Y gastrectomy

Objective To evaluate whether small endoscopic sphincterotomy (EST) plus balloon dilation (EPBD) can replace endoscopic sphincterotomy (EST) alone for patients with common bile duct (CBD) stones.Methods From May 2008 to April 2011,462 patients with CBD stones were randomly divided into two groups.The success rate of complete stone removal after the first session,the rate of using mechanical lithotripsy (ML),the short-term complications,the procedure time and fluo roscopy time were compared between the two groups.Results Overall ductal clearance did not differ between the two groups (96.5％ vs 93.5％,P＞0.05).The complication rates at 24 hours were 6.9％ for the small EST plus EPBD group and 11.7％ for the EST group (P＞0.05).However,the rate of complete stone removal after the first session using small EST plus EPBD was significantly higher than EST alone (86.2％ vs 70.4％,P＜0.05).ML was required significantly more often in the EST group when compared with the small EST plus EPBD group (34.8％ vs 12.1％,P＜0.05).The total procedure time and total fluoroscopy time in the small EST plus EPBD group were significantly shorter than the EST group [(38.6±15.5) min vs (47.1±20.2) min,P＜0.05 and (17.3± 7.0) min vs (26.5±10.8) min,P＜0.05].Conclusions Compared with EST,small EST plus EPBD was safe and more efficacious for bile duct stones.In the future,small EST plus EPBD probably can replace EST to be the first treatment of choice for bile duct stones. Key words: Cholelithiasis; Sphincterotomy, endoscopic; Balloon dilation

Endoscopic sphincterotomy (ES) with minimal incision followed by balloon dilation (ESBD) is a promising hybrid technique for the treatment of common bile duct (CBD) stones. However, balloon slippage during dilation can occur easily following ES due to partially opened papillae. This study aimed to examine the clinical utility of ESBD using a novel non-slip balloon catheter. This prospective pilot study included 100 eligible patients with CBD stones measuring ≤ 11mm. The study outcomes included the rates of technical success, adverse events (AEs), use of mechanical lithotripsy (ML), and successful stone removal associated with ESBD using a novel balloon catheter. The procedure was performed by trainees in 93% of the study cohort. ESBD was successful in 99% of the patients, while successful ESBD on the first inflation attempt without slippage was achieved in 98% of the patients. The median procedure time for ESBD, including the 2-min dilation hold time, was 4min. The rate of successful and complete stone removal in the first session was 98%. ML was required in 7% of the cases. The median procedure time for stone removal was 8min. The procedure-related AE rate was 3%. ESBD using the novel non-slip balloon achieved high procedural success and complete stone removal rates with very low rates of balloon slippage, AE, and ML use, even when the majority of procedures were performed by trainees.