Complete Duct Clearance Research Articles

Is the addition of choleretic agents in multiple double-pigtail biliary stents effective for difficult common bile duct stones in elderly patients? A prospective, multicenter study

Temporary biliary stenting is both technically easy and feasible, and choleretic agents such as ursodeoxycholic acid (UDCA) and a terpene preparation may promote a reduction in stone size. However, there are few comparative data on the effectiveness of choleretic agents available. To investigate the efficacy of multiple double-pigtail stents with or without UDCA and terpene on difficult common bile duct (CBD) stones. A prospective, multicenter study. Four tertiary-care referral centers. This study involved 51 patients. In total, 51 elderly patients with comorbidities who had difficult CBD stones refractory to conventional methods were randomized to receive either multiple 7F double-pigtail stents (group A) or stents in combination with UDCA and terpene (group B) for a period of 6 months. Stone size reduction, successful duct clearance, and complications. Complete endoscopic duct clearance was achieved in 14 patients (73.7%) in group A and 19 patients (86.4%) in group B (P = .826). The mean size of CBD stones (transverse/longitudinal diameter, mean ± SD) was 19.12 ± 4.48 mm/20.47 ± 3.86 mm in group A and 21.30 ± 7.08 mm/22.58 ± 7.61 mm in group B. Stone size decreased significantly to 12.04 ± 3.26 mm/13.31 ± 5.12 mm and 13.67 ± 5.40 mm/14.04 ± 6.12 mm, respectively (P < .01). However, there was no statistical difference in stone size reduction between the two groups (P = .685, P = .289). No serious complications related to the stent or endoscopic procedures were observed, except for cholangitis (n = 1, group A) and distal stent migration (n = 2, group B). Small number of patients in East Asia. Temporary multiple double-pigtail biliary stenting was a safe and feasible method of treating difficult and large CBD stones in elderly patients and contributed to a reduction in stone size and successful duct clearance. However, the addition of choleretic agents did not result in a statistical difference in stone size or rate of successful duct clearance.

Use of Spyglass® Direct Visualization for the Extraction of Cystic Duct Stones

Purpose: The Spyglass® Direct Visualization System (Boston Scientific) is a single operator system used to directly visualize the bile ducts and allows lithotripsy and biopsies under direct intra-luminal view. Spyglass has been increasingly utilized for difficult to extract cystic duct stones. Little data exists regarding its safety and efficacy for this purpose. The aim of this study was to determine if Spyglass is effective and safe for the extraction of cystic duct stones. Methods: We undertook a retrospective study evaluating all ERCPs performed using the Spyglass system for treatment of cystic duct stones from Oct 2005-Jan 2010 at our institution. We collected data on patient demographics, procedure indications, success, and complications. Primary outcomes were complete cystic duct clearance on first attempt and procedural complications. The secondary outcome was final duct clearance regardless of the number of attempts. Results: A total of 17 procedures in 14 patients were identified where ERCP with Spyglass was used for previously identified cystic duct stones. All patients had stones that were not amenable to extraction via traditional ERCP. The mean age was 57 +/- 18 yrs and 57% were female. Most patients were referred for Spyglass with abdominal pain and cystic duct stone identified on imaging or ERCP. Of the 17 procedures, 12 were done under conscious sedation or monitored anesthesia care and 5 were under general anesthesia. The mean procedure duration was 58.8 +/- 28.7 min. The median stone size was 8 mm (range 4 to 30 mm). In 1 patient, the cystic duct stone was no longer present at the time of Spyglass. Of the remaining 13 patients, complete cystic duct clearance on first attempt was achieved in 6 patients (46.2%). Two additional patients had successful cystic duct clearance after a second procedure. Thus complete duct clearance was achieved in a total of 8 patients (61.5%). Of the remaining 5/13 patients, 1 had partial extraction, while 4 had failed extraction. Reasons for failed extraction were impacted cystic duct stone (1), multiple CBD/cystic duct stones (1), tortuous cystic duct (1), and patient intolerance of the procedure (1). Two patients with failed extraction went on to surgical treatment, 1 had a clear cystic duct on repeat Spyglass, and 1 was lost to follow-up. There were no procedural or anesthesia related complications with Spyglass except for mild nausea and tachycardia in 1 patient. Conclusion: The Spyglass Direct Visualization System is safe and effective for the management of cystic duct stones. If available, Spyglass should be considered the procedure of choice in patients with failed cystic duct stone extraction during traditional ERCP. Disclosure: Sirish Sanaka MD - Stockholder (owns few stocks): Boston Scientific; Douglas Pleskow MD - Consultant: Boston Scientific; Ram Chuttani MD - Received educational grant support: Boston Scientific.

Large balloon dilation for the treatment of recurrent bile duct stones in patients with previous endoscopic sphincterotomy: preliminary results

Objective. Endoscopic sphincterotomy (ES) is an established method to treat common bile duct (CBD) stones. Inevitable sequence after ES is a substantial risk of recurrent choledocholithiasis and occasional difficulty in removal of large or multiple CBD stones after ES even when mechanical lithotripsy (ML) is employed. In turn, a new endoscopic technique, large balloon dilation (LBD) after ES, has been introduced. The objective was to analyze the efficacy and safety of LBD in patients with recurrent bile duct stones who have previously undergone ES. Patients and methods. From December 2007 to November 2009, 24 patients with recurrent choledocholithiasis and a history of ES were treated with LBD without additional ES. The size of the balloon for LBD was 15–20 mm and the duration of balloon dilation was 30 s. Results. Successful stone removal and complications such as perforation, pancreatitis, and bleeding were evaluated as procedure-related outcomes. Postoperative CBD stone recurrence was evaluated as the short term outcome. Complete duct clearance rate without using ML was 96% (23/24 patients) and all stone removal was achieved in one session. Failure to remove stones occurred in one (4.2%) patient. There were no procedure-related complications although one case of aspiration pneumonia occurred after the endoscopy. Recurrent choledocholithiasis after LBD was observed in 12.5% (3/24) of the cases overall. Conclusions. LBD is an effective and safe method in patients with recurrent choledocholithiasis not only to treat large stones but also to prevent further recurrence.

The Ballooning Time in Endoscopic Papillary Balloon Dilation for the Treatment of Bile Duct Stones

Background/AimsEndoscopic papillary balloon dilation (EPBD) is a safe and effective method for the treatment of choledocholithiasis, but previous studies have rarely reported the appropriate ballooning time (BT). We prospectively evaluated the safety and efficacy of EPBD according to BT in patients undergoing bile duct stone removal.MethodsSeventy consecutive patients with bile duct stones were randomly assigned to receive EPBD with either conventional (n = 35, 60 seconds) or short (n = 35, 20 seconds) BT.ResultsEPBD alone achieved complete bile duct clearance in 67 patients (long BT, n = 33, 94.3%; short BT, n = 34, 97.1%; p = 0.808). We also found no significant difference in the rate of complete duct clearance, including procedures that used mechanical lithotripsy, between the long and short BT groups (97.1% vs. 100%; p = 0.811). Mild pancreatitis was noted in four (11.4%) patients in the long BT group and two (5.7%) patients in the short BT group, but this incidence was not significantly different.ConclusionsThe study showed that EPBD using both 20-sec and 60-sec BTs is safe and effective for the treatment of bile duct stones. Short and long BTs produced comparable outcomes.

Efficacy and Safety of Therapeutic ERCP for the Elderly with Choledocholithiasis: Comparison with Younger Patients

To clarify the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography for the elderly with choledocholithiasis compared with younger patients. Consecutive therapeutic ERCPs performed between 2005 and 2007 at our institution for 118 patients aged 80 years or older (group A) and 205 patients younger than 80 years old (group B) were retrospectively reviewed. Successful cannulation rate, complete stone clearance rate, complications and prognosis were compared between the two groups. Successful cannulation was achieved in 99.2% in group A versus 99.5% in group B. The complete stone clearance rate was significantly lower in group A than in group B (92.4% versus 99.0%, p<0.01). Plastic stent placement was performed for patients with incomplete duct clearance. There was no significant difference in the early complication rate between group A (5.5%) and group B (6.6%). Procedure-related mortality did not occur. Cholangitis-free survival was similar between the two groups. The short-term prognosis was comparable between those with complete duct clearance and those with biliary stent placement. With a duct clearance rate of more than 90% and plastic stent placement for patients with poor general condition, therapeutic ERCP for choledocholithiasis in patients 80 years of age or older is comparable in safety and effectiveness to that in younger patients.

Ten years of Swedish experience with intraductal electrohydraulic lithotripsy and laser lithotripsy for the treatment of difficult bile duct stones: an effective and safe option for octogenarians

Endoscopic procedures using electrohydraulic lithotripsy (EHL) or intraductal laser lithotripsy (ILL) are the methods of choice for managing difficult common bile duct (CBD) stones. This retrospective study examined 10 years of Swedish experience using a mother-baby endoscopic system to assist in the fragmentation of CBD stones by EHL and ILL. Between 1995 and 2006, 44 patients with a median age of 80 years underwent EHL or ILL at two Swedish centers after conventional endoscopic fragmentation of CBD stones had failed. Long-term follow-up assessment was conducted for 9 to 126 months (median, 53 months). Final stone clearance after EHL or ILL treatment with or without additional conventional endoscopic retrograde cholangiopancreatography (ERCP) was achieved for 34 (77%) of 44 patients. The results for 10 patients (23%) were defined as failures. Complete or partial stone fragmentation and definitive duct clearance were achieved in one session for 23 patients (52%). A second EHL or ILL attempt made in five cases of primary failure led to definitive stone clearance in three cases. Two patients experienced perioperative complications (stone basket impaction). Mild post-ERCP pancreatitis occurred for one patient and cholangitis for two patients. During long-term follow-up evaluation, recurrent CBD stones were found in one patient. Peroral endoscopic EHL or ILL, under direct cholangioscopic visualization by a mother-baby endoscopic system, is an effective treatment for difficult CBD stones. The technique can be used safely even in frail and elderly patients. However, several endoscopic attempts may be required before final stone clearance is achieved. The vast majority of patients may be expected to remain symptom free for a prolonged period.

Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study

Endoscopic sphincterotomy (EST) has usually been performed before large-balloon sphincteroplasty (LBS) to retrieve large bile duct stones because of the high risk of pancreatitis and some advantages of EST. However, there are no available data on the preceding EST to confirm these assertions. We investigated the safety and efficacy of LBS without a preceding EST for the management of large bile duct stones. Single-institution retrospective study. Tertiary referral center. Thirty-eight patients with large bile duct stones. Endoscopic LBS without preceding EST. Efficacy of stone removal and complications related to the procedure. The overall success rate irrespective of whether mechanical lithotripsy (ML) was used was 97.4% (37/38). Complete duct clearance by LBS alone without ML was achieved in 29 (76.3%) patients. Complete stone retrieval was achieved by LBS alone in the first session in 25 (65.8%) patients. ML was required in 8 (21.1%) patients. Failure to extract a stone occurred in 1 (2.6%) patient. There was a mild degree of postprocedure pancreatitis in only 1 (2.6%) patient and asymptomatic hyperamylasemia in 3 (7.9%) patients. The maximum diameters of the stones and the balloon/stone diameter ratio had a tendency to affect complete stone retrieval in the success and failure groups: 16.7 +/- 3.9 mm vs 20.8 +/- 6.5 mm and 0.96 +/- 0.19 mm vs 0.80 +/- 0.23 mm, respectively (results are presented as mean +/- standard deviation). Small-scale, single-arm study. Our data suggest that LBS without EST is safe and effective in patients with large bile duct stones.

Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography

Periampullary diverticula (PAD) discovered incidentally during endoscopic retrograde cholangiopancreatography are usually asymptomatic, but can be a source of significant morbidity. The size of the diverticula and position of the papilla in relation to the diverticula are variable. The twofold aim of this study was to determine the prevalence of PAD in adult Indian patients and technical success of endoscopic retrograde cholangiopancreatography (ERCP). Patients with PAD (group I) were prospectively entered into a database from May 2006 to May 2007. Diverticula were categorized based on size into small (<1.5 cm) and large (>1.5 cm). Papilla was arbitrarily defined as type A when located outside the diverticulum and type B when the position was intradiverticular. Requirement of needle knife papillotomy (NKP), sphincterotomy, and overall success/failure of the procedure were recorded. One hundred consecutive patients without PAD undergoing ERCP served as controls (group II). PAD were present in 46 (7.5%) of the 600 patients undergoing ERCP for various indications (group I). Mean age of patients with PAD (51 +/- 15 years) was significantly higher than control group (39 +/- 17 years) (p < 0.001). Of the 46 diverticula, 26 diverticula (56.5%) were large. In small diverticula, the papilla was extradiverticular (type A) in all 20 (100%) patients, whereas in the group with diverticula >1.5 cm only 57% was extradiverticular. Successful cannulation was achieved in 97% (45/46). NKP was done in six patients, five of whom had type A papilla. There was a significant high rate of NKP inpatients without PAD compared with patients with PAD (p = 0.001), whereas the rate of endoscopic papillotomy (EPT) was similar in both groups. Complete common bile duct (CBD) clearance was achieved in 93% patients in PAD group as compared with 96% in the non-PAD group (p = nonsignificant). Complications after ERCP were similar in both groups. PAD were present in 7.5% of patients. Fifty-six percent of PAD were large and in the vast majority (76%) papilla was extradiverticular in location. PAD were not associated with an increased risk of EPT-related complications.

Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study

The search for an easier and less cumbersome technique to perform direct visual examination of the biliary tree is still underway. To assess the feasibility of performing endoscopic direct cholangioscopy utilizing an ultra-slim upper endoscope designed for pediatric patients. Prospective, observational, pilot study. Tertiary referral center. Three patients who underwent endoscopic retrograde cholangiography for evaluation and treatment of choledocholithiasis. Following the completion of the endoscopic retrograde cholangiography, a 0.035-inch diameter super-stiff Jagwire (Boston Scientific Corp, Natick, Mass) was placed in the common bile duct. Using the wire to maintain access, we removed the duodenoscope and backloaded the wire onto an ultra-slim upper endoscope (GIF-XP 160, Olympus America Inc, Melville, NY), which was advanced over the guidewire under fluoroscopic and endoscopic control into the duodenum and then across the ampulla of Vater into the common bile duct and upstream. Endoscopic direct cholangioscopy was attempted and successfully completed in all 3 patients. One patient was found to have persistent large amount of sludge and stones, and was referred for surgery. In the other two patients, endoscopic direct cholangioscopy demonstrated complete duct clearance, obviating the need for stent placement and repeat endoscopic retrograde cholangiography procedures. Small sample size, pilot study. Endoscopic direct cholangioscopy with an ultra-slim upper endoscope originally designed for pediatric use is feasible. Future advances in endoscope development, as well as specifically designed accessories, could lead to the next generation of intraductal diagnosis and therapy.

Simultaneous Endoscopic Papillary Large Balloon Dilatation and EST for Easy Removal of Large and Multiple CBD Stones

Background/Aims: Extraction of large bile duct stones after endoscopic sphincterotomy (EST) is only successful in 80 ∼ 90% of cases and it often requires prolonged time and repeated trial. We investigated the usefulness of simultaneous endoscopic papillary large balloon dilatation and EST method for removal of large and multiple common bile duct (CBD) stones. Methods: Twenty patients with large or multiple CBD stones (size of stones were more than 15 mm) were enrolled. Endoscopic papillary balloon dilatation was carried out with one-step inflation of a 15 mm or 18 mm diameter balloon after mid incision of papilla with a pull type sphincterotome. The success and complication rate for duct clearance were evaluated prospectively. Results: Maximal stone diameter was 21.71 ± 5.45 mm (range 16.1- 34.8 mm). Seven patients had more than 4 stones, 3 patients had 2 stones, and the other patients had a single large stone. Complete duct clearance was achieved in 100% of patients. All the large CBD stones were captured with stone basket and easily pulled out via widely opened papilla. After the procedure, serum amylase and/or lipase levels were elevated in 6 patients (27.3%). However, no episode of true pancreatitis happened. Minor bleeding occurred in only one patient (4.5%) and was easily controlled by Argon-plasma coagulation. No procedure-related perforation or mortality was observed. Conclusions: Simultaneous endoscopic papillary large balloon dilatation and EST method is a safe and effective method in the treatment of large and multiple CBD stones. This method may be a good alternative treatment to mechanical lithotripsy for the treatment of large and multiple CBD stones. EST may be in a role of good guiding of papillary dilatation with large balloon and less injured to the pancreatic duct.

Management of common bile duct stones using a second-generation extracorporeal shockwave lithotriptor.

Fifty-four patients with common bile duct stones (8-36 mm in diameter) that could not be removed after endoscopic sphincterotomy, even with the use of mechanical lithotripsy, underwent extracorporeal shockwave lithotripsy (ESWL) using a Siemens Lithostar. Their median age was 75.5 (range 34-89) years. Patients received 4000-6000 shocks per session over approximately 60 min. Seventeen underwent two sessions and two patients three or more. Thirty-seven patients had one stone, ten had two, and seven had three or more. Spontaneous clearance of fragments occurred in only three patients before further endoscopic retrograde cholangiopancreatography was performed to remove fragments. Stones were removed and ducts cleared endoscopically in 35 patients, giving a total of 38 of 54 patients (70 per cent) with complete duct clearance. Fragmentation in response to lithotripsy was dependent on stone size; the number of stones had little effect. ESWL was well tolerated without any haematological or biochemical abnormality. Computed tomography in the first 20 patients showed no hepatic or pancreatic change after treatment. ESWL combined with endoscopic extraction of fragments is an alternative to surgery when preliminary endoscopic extraction and mechanical lithotripsy have failed.

Flushing technique in the management of retained common bile duct stones with a T tube in situ.

Over a 12-year-period, 6046 cholecystectomies and 918 common bile duct explorations were undertaken with 697 stone-positive choledochotomies (76 per cent). Forty patients (5.7 per cent) had retained common bile duct stones with a T tube in situ. Twenty-eight patients underwent flushing of the common bile duct with a continuous infusion of heparinized saline solution with parenteral aminophylline to induce relaxation of the sphincter of Oddi. Complete duct clearance was achieved in 17 patients; infusion was stopped in four patients and no deaths occurred. The use of percutaneous stone extraction (Burhenne's technique), gave an overall successful common bile duct clearance rate of 86 per cent. The flushing technique represents the first step in the non-operative management of retained common bile duct stones in patients with a T tube in place. It is a safe and effective method for use in the early postoperative period with a prolongation of hospital stay of not more than 1 week.

Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones

Safety and Efficacy of Endoscopic Sphincterotomy and Bile Duct Clearance in Patients with Acute Cholangitis Due to the Common Bile Duct Stones Neven Ljubicic, Luka Rotkvic Background: It has been shown that urgent endoscopic drainage is an effective treatment for acute cholangitis and is superior to surgical drainage with a better clinical outcome Because of the risk of post-sphincterotomy bleeding in these patients many endoscopists have advocated endoscopic drainage by using nasobiliary catheter or an indwelling stent without sphincterotomy. The aim of this study was to analyze safety and efficacy of endoscopic sphincterotomy (ES) and urgent stone extraction in patients with acute cholangitis due to the common bile duct stones.Methods: Between January andDecember 2002, one hundred and eleven patients with clinical jaundice and common bile duct stones were enrolled to an ES and urgent stone extraction. ES has been performed in a standard manner, always using the guide-wire. In patients with cholangitis vigorous washing of the common bile duct has been performed after removal of the stones. Forty-six patients fulfilled criteria for acute cholangitis. Prior to the ES all patients received intravenously ciprofloxacin for at least 24 hours. Results: ES has been performed successfully in 102 (92%) patients. Complete duct clearance has been achieved in 90% of patients without cholangitis and in 93% of patients with cholangitis (not significant). Complications occurred in 12% of patients without and in 16% of those with acute cholangitis (Table). In patients with post-sphincterotomy bleeding blood transfusion was not required. The median lengths of time for resolution of jaundice in patients with and without cholangitis were similar. Significant coagulopathy has been observed in two (4.5%) patients with acute cholangitis. In those patients there were no bleeding occurred after ES. Conclusions: ES and bile duct clearance is very effective and safe method even in the patients with acute cholangitis. Mild bleeding was the most common postsphincterotomy complication not required blood transfusion even in the presence of coagulopathy. *T1500 MRCP Vs ERCP: A Comparative Study in Diagnosis of Common Bile Duct Stones Luigi T. Familiari Background: Because it is a noninvasive method, without complications, the magnetic resonance cholangiography (MRCP) is going to reliably replace ERCP in the diagnosis of pancreato-biliary diseases. Althoughmany studies documented a high sensitivity and specificity of MRCP, its ability in detecting microlithiasis ( 270; I-GT > 50 UI/l). Patients underwent upper abdominal ultrasonography (US), thenMRCP and, within 72 h, diagnostic and/or operative ERCP. All patients signed an informed consent. The statistical analysis was based on the report of true positives and negatives, false positives and negatives. Results:106/123 patients completed the study. MRCP diagnosed lithiasis of CBD in 73; did not document stones in 33. ERCP confirmed the presence of lithiasis in 66/73 pts who were submitted to ES. Seven were not found to have stones after ES.Among 33 negative pts, ERCPdocumented stones in 9: in 4 only after ES (it was performed according to clinico-biochemical data and to CBD dilation, though ERCP did not identify stones). The stones were 2-3 mm. In 24/33 patients negative at MRCP, ERCP confirmed this response:10/24 were submitted to ES. ES was not performed in 14/24 subjects, without CBD dilation and/or cholestasis. After a 27.8 months follow-up (range: 4-54), 8/14 remained asymptomatic, 6 underwent laparoscopic cholecystectomy without finding of CBD stones at the intra-operative cholangiography. The sensitivity, specificity, diagnostic accuracy, PPV and NPV of MRCP were: 88%, 77%, 85%, 90%, 73%. Conclusions: asMRCPhas still a limitation in the diagnosis of small stones,missed at US, it leaves unrisolved the question of which patient is candidate to ERCP/ES. The recognition of microlithiasis should refer to other imaging techniques preliminar to ERCP (e.g. EUS) though their limited availability makes until now MRCP a method of choice in the diagnosis of biliary disease.

Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: a prospective randomized controlled multicenter trial

Endoscopic papillary balloon dilatation may be an alternative to endoscopic sphincterotomy in the treatment of bile duct stones. However, there is a controversy as to the effectiveness and safety of endoscopic papillary balloon dilatation. Two hundred eighty-two patients with bile duct stones were enrolled and randomized to an endoscopic sphincterotomy or endoscopic papillary balloon dilatation group. The success rate for duct clearance as well as the frequency and types of complications were evaluated prospectively. Endoscopic sphincterotomy was performed in a standard manner. Endoscopic papillary balloon dilatation was carried out with gradual inflation of a 4-, 6-, or 8-mm diameter balloon. Complete duct clearance was achieved in 100% in the endoscopic sphincterotomy group and 99.3% in the endoscopic papillary balloon dilatation group (not significant). Complications occurred in 11.8% of patients in the endoscopic sphincterotomy group and 14.5% of those in the endoscopic papillary balloon dilatation group (not significant). No complication was severe; there was no mortality. The frequency of acute pancreatitis was higher in the endoscopic papillary balloon dilatation group than the endoscopic sphincterotomy group (respectively, 10.9% vs. 2.8%; p < 0.045). Hemorrhage occurred only in the endoscopic sphincterotomy group. Endoscopic sphincterotomy and endoscopic papillary balloon dilatation were approximately equal in terms of successful clearance of bile duct stones. They were also similar with respect to overall complications. Endoscopic papillary balloon dilatation is an alternative to endoscopic sphincterotomy as a treatment of bile duct stones.

Transnasal extraction of residual biliary stones by Seldinger technique and nasobiliary drain

Background: Complete endoscopic clearance of bile duct stones is unsuccessful in up to 30% of patients at the first attempt, necessitating further endoscopic procedures. A novel transnasal approach for extraction of these residual stones using Seldinger technique and a nasobiliary drain was evaluated. Methods: Twenty-one patients with residual biliary stones after ERCP underwent transnasal extraction under fluoroscopy without sedation. A 0.035-inch guidewire was inserted though the previously placed nasobiliary drain into the intrahepatic ducts. The nasobiliary drain was removed, leaving the guidewire in place. A double-lumen extraction balloon was inserted over the guidewire. Multiple withdrawal maneuvers of the inflated balloon were performed to clear the bile duct. Results: Residual stones were present in the extrahepatic and intrahepatic ducts in, respectively, 18 and 3 patients. The mean largest stone diameter was 5.9 mm (range, 3-12 mm). Seventeen patients had a single stone. Complete duct clearance was achieved in 17 patients (81%). The procedure was unsuccessful because of guidewire dislodgement in 3 patients and inability to pass the guidewire through the nasobiliary drain in 1 patient. There was no procedure-related complication. Conclusions: Transnasal extraction of residual biliary stones after ERCP with the Seldinger technique is safe and feasible with reasonable success and can avoid the inconvenience and cost of a repeat ERCP. (Gastrointest Endosc 2002;56:233-8.)

4677 Endoscopic treatment of 64 patients with mirizzi`s syndrome.

Background: Mirizzi`s syndrome is defined as extrinsic compression of the common bile duct by an impacted stone in the cystic duct or the neck of the gallbladder. Surgery is often difficult due to extensive inflammation. Aim: Evaluation of endoscopic treatment of Mirizzi`s syndrome in the largest series reported yet. Methods: Retrospective evaluation of patients (pts) presenting with Mirizzi`s syndrome between 1990 and 1999.For initial stabilisation or safe transport to our center, temporary stents or nasobiliary drainage (NBD) were placed. If the stone could be caught into the Dormia basket, mechanical lithotripsy (ML) was performed. Otherwise electrohydraulic lithotripsy (EHL) using the Mother-Baby scope system (Olympus Co.,Tokyo, Japan) and the Walz lithotriptor (Fa. Walz, Rohrdorf, Germany) was performed to fragment stones under cholangioscopic view. Results: 48 f and 16 m pts with a median age of 71years (14-94y) were included. Median duration of biliary symptoms was 22 days (1 d-5 y). Patients presented with pain in 64%, obvious jaundice in 66% and painless jaundice in 22%. 19% were in poor general condition. 9 pts had undergone cholecystectomy median 3 y before (0.1-23 y). An initial endoscopic stent or NBD was placed in 30 pts (47%). Median size of stones was 2cm (0.7- 5cm). In 8 pts ML was performed. 52 pts required EHL. Complete duct clearance was achieved in 59 pts (92%). A single lithotripsy session was sufficient in 54 pts. 4 pts were treated by stenting or nasobiliary drainage only. A complicated course was observed in 4 pts: 2 pts with cystic duct leak at the site of pressure necrosis recovered conservatively.A 71y male not sent for the 2nd session of lithotripsy was treated with long term stenting in another hospital and developed small bowel perforation by the dislodged stent. A 90 y female with septicemia treated by NBD, had myocardial infarction after 2 d and died after 3 d. Subsequently, 12 pts underwent cholecystectomy. 4 of them were symptomatic after endoscopy due to cholelithiasis (3 patients had cholecystitis after 7 d, 7 d and 56 d, respectively; 1 pt had biliary colics after 2 y). 39 pts did not undergo surgery and have remained asymptomatic over a median follow up of 28 months (2-82). None of the pts developed biliary malignancy over a median follow up of 24 (0-85) months. Conclusion: Mirizzi`s syndrome, being considered a clear indication for surgical management, can be safely and effectively treated by endoscopy even in elderly and severely ill pts. Coincidence of gallbladder malignancy with Mirizzi`s syndrome was not observed.

4679 Mother and baby cholangioscopy. a single centre experience, indications and limitations.

Peroral Mother and Baby cholangioscopy (MBC) allows direct visualization of the biliary tree. The proceedure requires a dedicated duodenoscope (Mother scope) with a 5.5mm therapeutic channel through which a 4.5mm choledochoscope (baby scope) can instrument the biliary tract. The baby scope has bi-directional tip control and a therapeutic channel allowing brushings, biopsies, electrohydraulic lithotripsy (EHL) and laser lithotripsy to be undertaken. Methods: MBC has been undertaken at our institution from November 1992 in the treatment of selected patients and lesions which have resisted conventional endoscopic treatments or provided diagnostic diffeculties. All EHL was carried out with a Piezo electric lithotripter. Results: From November 1992 to March 1999, cholangioscopy was performed on 18 occasions in 16 patients (44% female and 56% male) with a median age of 64 (range 42-82 years). Choledocholithiasis was the indication in 14 patients (10 single stones, 4 multiple stones). In two patients the stones spontaneously cleared and no further action was required. EHL was performed in 12 patients, facilitating complete duct clearance in seven. Clearance was not possible in five patients, two were stented and remain well, three underwent surgical exploration of the common bile duct. In two of the 16 patients diagnostic MBC was performed, one for a problematic right hepatic ductal stricture which MBC revealed to be an unusual case of pan-sclerosing cholangitis. The 2nd patient had a right hepatic duct mass thought to be an impacted stone, MBC diagnosed an unusual case of biliary papillomatosis. A 100% success rate in intubation of the common bile duct was achieved and no proceedure related complications were encountered. Conclusion: Most stones can be delt with via conventional therapeutic ERCP, however experience has formulated the following indications for MBC. Lithotripsy of a single large ductal stone and impacted stones. Diagnosis of unusual strictures and filling defects. Limitations to MBC are multiple stones and CBD diameter (preferably ≥ 8mm). All patients undergo prior ERCP and sphincterotomy and at MBC balloon dilation of the ampulla is performed prior to insertion of the choledochoscope.

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

Background: Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F “baby” endoscope to administer electrohydraulic lithotripsy. Methods: Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization. Results: Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months’ duration following their final procedure. Conclusion: Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.