Complete Ductal Clearance Research Articles

Surgeon-Performed Percutaneous Endoscopic Biliary Lithectomy: Description of a Novel Technique and Initial Results.

Introduction: Percutaneous endoscopic biliary lithectomy (PEBL) can be performed through preexisting drain tracts, offering ductal clearance and definitive management for patients with complicated gallstone disease unable to undergo conventional therapy. The technique has not been widely adopted by general surgeons. Herein, we describe our technique with surgeon-performed PEBL and present initial results. Materials and Methods: A single institutional retrospective review of the electronic medical record was performed for patients who underwent percutaneous choledochoscopy between February 2019 and November 2020. All operations were performed by 1 of 2 board-certified general surgeons with fellowship training in surgical endoscopy. Preoperative, operative, and postoperative variables were analyzed using descriptive statistics. Results: Thirteen patients underwent PEBL. Seventeen total procedures were performed; 4 patients underwent repeat intervention. The diagnoses leading to PEBL were: cholelithiasis (8), choledocholithiasis (4), and recurrent pancreatitis (1). Complete ductal clearance was achieved in 9 patients (69.2%) during the initial procedure. The remaining 4 patients (30.8%) underwent repeat PEBL, at which point complete ductal clearance was then achieved. The percutaneous drain was removed at the time of final procedure in 5 patients (38.5%) or within 5 weeks in the remaining 8 (61.5%). No intraoperative complications occurred, and no pancreatic or biliary postoperative complications or recurrences were noted with a mean follow-up of 279 ± 240 days. Conclusion: Surgeon-performed PEBL is a safe and effective method of achieving biliary ductal clearance. The technique is readily achieved following basic endoscopic and fluoroscopic principles and should be understood by all physicians managing gallstone disease.

Assessment of pancreatic ductal stone density on non-contrast computed tomography for predicting the outcome of extracorporeal shock wave lithotripsy.

Background and study aims The utility of stone density at non-contrast computed tomography (NCCT) for predicting the effectiveness of extracorporeal shock wave lithotripsy (ESWL) in chronic calcific pancreatitis (CCP) is relatively unexplored. Patients and methods This was a prospective observational study of patients with CCP. Hounsfield units (HU) were determined for the largest pancreatic ductal stone during pretreatment NCCT. All patients underwent ESWL until the largest stone was fragmented to <3mm, followed by endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction. The predictive factors following ESWL for successful stone extraction were studied and the receiver operating characteristic (ROC) curve determined the HU optimal cut-point. Results Eighty-two patients with a median (interquartile range) age of 36 years (range, 29-55); majority male 45 (54.9%), were included. Idiopathic CCP was noted in 78 patients (95.1%). The median stone density (SD) was 1095 HU (range, 860.7-1260.7) and the number of ESWL sessions was 2 (range, 2-3). Complete stone removal at index ERCP was achieved in 55 patients (67.1%). Those with partial clearance (n=27) needed a repeat ERCP, which was successful in 26 (96.3%); one patient (3.7%) underwent surgery. There was a significant, positive correlation between number of ESWL sessions and SD (r=0.797; P <0.001). On bivariate analysis, SD and the number of ESWL sessions revealed a significant association with complete ductal clearance. The optimal cut-point for complete stone removal by the ROC curve was 1106.5 HU (Youden index 0.726), with a sensitivity of 93% and a specificity of 80%. Conclusions The SD is a significant predictor of ESWL success followed by ductal clearance at ERCP, and <1106.5 HU is a predictor of good candidates for ESWL therapy.

Biliary Ascariasis Causing Obstructive Jaundice: A Case Report on ERCP-Assisted Management

BACKGROUND: Biliary tract disorders are predominantly caused by cholelithiasis (gallstones). However, in regions endemic for parasitic infestations, or areas with poor hygiene and sanitation, hepatobiliary disorders may be due to an underlying worm infestation. THE CASE A 55-year-old female from Skardu, Pakistan, an Ascariasis-endemic area, presented to a tertiary care hospital with right hypochondrial pain and jaundice. Her condition did not respond to conservative treatment. Ultrasound (USG) and Magnetic Resonance Cholangiopancreatography (MRCP) identified multiple worms obstructing the common bile duct. Subsequently, an Endoscopic Retrograde Cholangiopancreatography (ERCP) procedure was performed, successfully retrieving the worms and achieving complete ductal clearance. The patient was discharged with oral anthelmintics and made a full recovery. CONCLUSION: This case underscores the importance of considering biliary ascariasis as a differential diagnosis for obstructive jaundice in endemic regions. MRCP emerges as a valuable diagnostic tool, providing a non-invasive and precise way to identify worm infestations of the biliary system. It effectively reduces the dependence on ERCP and its associated risks, reserving ERCP for therapeutic interventions. Equipping local healthcare centers in Ascariasis-endemic regions with the necessary resources to diagnose and treat these conditions is essential for mitigating patient suffering. This may lessen the need for travel to larger hospitals, minimising physical and financial inconveniences to the patient while also decreasing the burden on tertiary care hospitals.

Outcome of long-term biliary stenting for stones in the 2010s: beware the cholecystectomised!

ObjectiveEndoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for most patients with common bile duct stones (CBDS). Duct clearance at initial ERCP may not be achieved in a third...

A204 SINGLE OPERATOR CHOLANGIOSCOPY GUIDED ELECTROHYDRAULIC LITHOTRIPSY THROUGH A UNIQUE PERCUTANEOUS ACCESS FOR SEVERE RECURRENT PYOGENIC CHOLANGITIS: A CASE REPORT

Abstract Background Single operator cholangioscopy guided electrohydraulic lithotripsy (SOC-EHL) is effective in difficult biliary stones. SOC is usually introduced in a transpapilliary fashion via a duodenoscope (peroral SOC). This approach is limited in intrahepatic ductal access, especially in presence of distal strictures. Aims To report a case of ductal clearance using a unique percutaneous access of SOC-EHL in a patient with extensive intrahepatic stones in addition to a distal stricture. Methods A retrospective case report Results An 80 year old male known for a distal cholangiocarcinoma post-Whipple surgery presented with recurrent cholangitis. Computed tomography scan revealed dilated intrahepatic bile ducts in segments V and VII and a dilated posterior right hepatic duct (PRHD) with associated cholelithiasis. Peroral SOC was first performed using a therapeutic gastroscope. The hepaticojejunostomy was patent and the cholangioscope was easily introduced into the bile duct. No stones or strictures were found on inspection of the intra- and extra-hepatic biliary system. Due to cholangitis recurrence a left-sided percutaneous drain was placed. However, cholangiogram showed a normal biliary sytem with no filling defects. A right-sided PTC was then performed for source control. Repeat right-sided cholangiogram finally identified an extremely dilated PRHD with extensive filling defects and a stricture in the distal PRHD. The abnormal biliary segments were missed on peroral SOC and left-sided cholangiogram due to the tight stricture. Percutaneous SOC-EHL was then planned. The abnormal segment could not be reached using the right sided access. The left system did not allow for easy PRHD access due to the stricture and angulation. In order to gain entry to the abnormal biliary segment, the PRHD stricture was dilated to 6mm with balloon angioplasty. A 0.035” guidewire was inserted from the left access and advanced to the extrahepatic bile duct. This wire was captured using a snare introduced from the right percutaneous access and pulled through the right side. This allowed wire tension to be optimally applied from both percutaneous accesses. A cholangioscope was then introduced over the wire from the left access and advanced into the abnormal PRHD with optimal wire tension at both ends. A large stone burden was noted on SOC and ductal clearance with EHL was achieved after two EHL sessions (Fig. 1). Final cholangiogram showed complete ductal clearance and there was no recurrence of cholangitis at an 18 month follow-up. Conclusions SOC-EHL is an important therapeutic modality but may be of limited effectivess for extensive intrahepatic stones. Our case suggests the possibility of using a percutaneous approach for SOC-EHL in intrahepatic stones with concomitant distal stricture. Figure 1: A) Cholangiogram showing extensive intrahepatic stone burden; B) SOC-EHL via a percutaneous access with EHL; C) final cholangiogram showing complete ductal clearance. Funding Agencies None

Utility of Direct Peroral Cholangioscopy Using a Multibending Ultraslim Endoscope for Difficult Common Bile Duct Stones

Background/AimsTreatment options for difficult bile duct stones are limited. Direct peroral cholangioscopy (POC)-guided lithotripsy may be an option. A newly developed multibending (MB) ultraslim endoscope has several structural features optimized for direct POC. We evaluated the utility of direct POC using an MB ultraslim endoscope for lithotripsy in patients with difficult bile duct stones.MethodsTwenty patients with difficult bile duct stones, in whom stone removal using conventional endoscopic methods, including mechanical lithotripsy, had failed were enrolled from March 2018 to August 2019. Direct POC-guided lithotripsy was performed by electrohydraulic lithotripsy or laser lithotripsy. The primary outcome was complete ductal clearance, defined as the retrieval of all bile duct stones after lithotripsy confirmed by balloon-occluded cholangiography and/or direct POC.ResultsThe technical success rate of direct POC was 100% (20/20), and the free-hand insertion rate was 95% (19/20). Direct POC-guided lithotripsy, attempted by electrohydraulic lithotripsy in nine patients (45%) and laser lithotripsy in 11 patients (55%), was successful in 95% (19/20) of the patients. Complete ductal clearance after direct POC-guided lithotripsy was achieved in 95% (19/20) of patients. Patients required a median of 2 (range, 1–3) endoscopic retrograde cholangiopancreatography sessions for complete stone removal. Adverse event was observed in one patient (5%) with hemobilia and was treated conservatively.ConclusionsDirect POC using an MB ultraslim endoscope was safe and effective for lithotripsy in patients with difficult bile duct stones.

Laparoscopic common bile duct exploration after failed endoscopic retrograde cholangio-pancreatography: Our patient series over a period of 10 years.

Laparoscopic CBD exploration (LCBDE) for Common bile duct (CBD) stones with laparoscopic cholecystectomy (LC) is an alternative to open CBD exploration, in patients with failed endoscopic retrograde cholangio-pancreatography (ERCP). It is being performed at few centres with adequate surgical expertise. Herein, we present our experience of LCBDE with LC over a period of 10 years. A retrospective analysis of prospectively recorded data of 121 consecutive patients was performed from February 2010 to November 2019, who underwent LC and LCBDE by choledochotomy in a single surgical unit. These included all patients with failed pre-operative ERCP. Out of 121 patients, LCBDE successfully cleared the CBD in 118, and three patients were converted to open surgery. All these patients underwent choledochotomy for adequate exploration of CBD. T-tube closure of CBD was performed in 103 patients and removed after a mean of 14.6 ± 2.4 days. Primary closure was performed in 15 patients. The mean hospital stay post-procedure was 3.4 ± 0.7 days. Complete ductal clearance was achieved in 115 patients, and residual stone fragments reported in three patients were removed by ERCP. None of the patients experienced biliary peritonitis, biliary fistula, pancreatitis or cholangitis. There was no 30-day mortality and no recurrent stones reported with a mean follow-up of 12.4 ± 3.9 months. With adequate surgical expertise, LCBDE is a feasible alternative to open surgery for CBD stones after failed ERCP with early recovery and low morbidity.

Factors Influencing Performance of Cholangioscopy-Guided LithotripsyIncluding Available Different Technologies: A Prospective Multicenter Study with 94 Patients.

Peroral cholangioscopy (POC)-guided lithotripsy is an effective treatment for difficult biliary stones. A clear definition of factors associated with the efficacy of POC-guided lithotripsy in one session and the performance of electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL) have not clearly emerged. This was a non-randomized prospective multicenter study of all consecutive patients who underwent POC lithotripsy (using EHL and/or LL) for difficult biliary stones. The primary endpoint of the study was the number of sessions needed to achieve complete ductal clearance and the factors associated with this outcome. Secondary endpoints included the evaluated efficacies of LL and EHL. Ninety-four patients underwent 113 procedures of EHL or LL. Complete ductal clearance was obtained in 93/94 patients (98.94%). In total, 80/94 patients (85.11%) achieved stone clearance in a single session. In the multivariate analysis, stone size was independently associated with the need for multiple sessions to achieve complete ductal clearance (odds ratio = 1.146, 95% confidence interval: 1.055-1.244; p = 0.001). Using ROC curves and the Youden index, 22mm was found to be the optimal cutoff for stone size (95% confidence interval: 15.71-28.28; p < 0.001). The majority of the patients (62.8%) underwent LL in the first session. Six patients failed the first session with EHL after using two probes and therefore were crossed over to LL, obtaining ductal clearance in a single additional session with a single LL fiber. EHL was significantly associated with a larger number of probes (2.0 vs. 1.02) to achieve ductal clearance (p < 0.01). The mean procedural time was significantly longer for EHL than for LL [72.1 (SD 16.3min) versus 51.1 (SD 10.5min)] (p < 0.01). POC is highly effective for difficult biliary stones. Most patients achieved complete ductal clearance in one session, which was significantly more likely for stones < 22mm. EHL was significantly associated with the need for more probes and a longer procedural time to achieve ductal clearance.

Efficacy and safety of cholangioscopy guided laser lithotripsy for difficult bile duct stones – A prospective study from a tertiary care centre in Eastern India

Background and study aimsEndoscopic sphincterotomy combined with endoscopic papillary balloon dilatation, mechanical lithotripsy or both, are effective modalities for the ex- traction of difficult common bile duct (CBD) stones. However, approximately 5–15% of cases are still difficult to treat. In the present study, we have evaluated the safety and efficacy of single- operator cholangioscopy guided laser lithotripsy (LL) for difficult to treat CBD stones. Patients and methodsConsecutive patients undergoing LL for the extraction of difficult CBD stones were enrolled in the study. The primary outcomes were related to the efficacy of the procedure in terms of ductal clearance and safety in terms of complications. ResultsDuring the 36 months, 764 patients presented for biliary stone extraction. Most of the patients, 683 (89.4%), had a successful stone extraction with standard techniques. Thirteen patients (1.7%) were not suitable for endoscopic therapy or did not consent for endoscopic therapy, and were referred directly for surgical treatment. Sixty-seven patients (8.8%) were included in the study. Cholangioscope was able to reach the stone in all the cases but one. Complete ductal clearance was achieved in 61 (91%) patients. Complications were encountered in 8 (11.9%) patients. All patients were asymptomatic at one-month of follow-up. ConclusionLL is a highly effective and safe procedure with minimal and transient complications.

Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective.

Background and Aims:Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis.Methods:A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases.Results:The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295.Conclusions:Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

S3242 Diagnostic and Therapeutic Utility of Spyglass Digital Probe in the Evalutation and Treatment of Pancreatobiliary Disorders

INTRODUCTION: Single operator cholangioscopy (SOC) and SpyGlass Digital System ‘‘DS” (Boston Scientific Corp, MA, USA) have allowed for visualization of the biliary tract and enabled optically guided biopsies to be performed. Our study evaluated the experience of a high-volume tertiary care center in the management of PB disorders and assess success rates and patient outcomes using SOC and the latest version of SpyGlass DS. METHODS: A retrospective analysis from Nov. 2015 and Sept. 2019 was performed on patients referred for SOC with SpyGlass DS guided intervention for pancreaticobiliary disorders at a single tertiary care center. For stones case, TS was defined as ability to visualize the PB system and perform stone fragmentation/removal. CS was defined as the ability to achieve complete ductal stone clearance after a single procedure. For cases evaluating strictures, TS was defined as the ability to visualize the target lesions. The diagnosis made from the most concerning impression (Spyglass visual +/- Spybite tissue) was compared to the final clinical/surgical pathology diagnosis. Sensitivity (Sn), specificity (Sp), positive predictive value (PPV), and diagnostic accuracy (DA) were taken as markers for CS. RESULTS: 1,542 patients were referred for an ERCP procedure. The SpyGlass DS was used in 151 of those cases for the management of PB disorders. 59 (39.1%) required SOC with stones as their preprocedural indication and 92 (60.9%) patients required SOC with stricture as a preprocedural indication. CS rate after a single procedure was 83.1% (49/59). Only 3.4% (2/59 patients) experienced adverse events which included periampullary edema and post procedure bleeding. 69.6% (64/92) of the cases had SpyBite directed biopsy samples taken and 96.9% (62/64) of those samples were deemed adequate for analysis. Out of the 92 patients, 40 of them were diagnosed benign strictures, 37 with malignant strictures, and 15 with indeterminate strictures. The SOC DS diagnosis Sn was 86.7%, Sp was 76.6%, PPV was 70.3%, and DA was 80.5% when differentiating between benign or malignant strictures. CONCLUSION: Our institution’s experience with SOC using SpyGlass and SpyBite technologies offered a practical, efficient, and safe tool for visual/histologic diagnosis of biliary and treatment of difficult bile duct stones. These favorable outcomes provide evidence for diagnostic and therapeutic utility of these cholangioscopic advancements in managing PB disorders.Table 1.: Pancreaticobiliary Stone Patients ParametersTable 2.: Stricture Patient ParametersTable 3.: SpyGlass DS +/- Spybite tissue impression vs final diagnosis

Success of extracorporeal shock wave lithotripsy and ERCP in symptomatic pancreatic duct stones: a systematic review and meta-analysis.

Background and study aims Pain is the most frequent and dominant symptom of chronic pancreatitis. Currently, these patients are treated using a step-up approach, including analgesics and lifestyle adjustments, endoscopic, and eventually surgical treatment. Extracorporeal shock wave lithotripsy (ESWL) is indicated after failure of the first step in patients with symptomatic intraductal stones larger than 5 mm in the head or body of the pancreas. To assess the complete ductal clearance rate and pain relief after ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones, a systematic review and meta-analysis was performed. Patients and methods A systematic literature search from January 2000 to December 2018 was performed in PubMed, the Cochrane Library, and EMBASE for studies on ductal clearance rate of ESWL in patients with symptomatic chronic pancreatitis with pancreatic duct stones. Results After screening 486 studies, 22 studies with 3868 patients with chronic pancreatitis undergoing ESWL for pancreatic duct stones were included. The pooled proportion of patients with complete ductal clearance was 69.8 % (95 % CI 63.8–75.5). The pooled proportion of complete absence of pain during follow-up was 64.2 % (95 % CI 57.5–70.6). Complete stone fragmentation was 86.3 % (95 % CI 76.0–94.0). Post-procedural pancreatitis and cholangitis occurred in 4.0 % (95 % CI 2.5–5.8) and 0.5 % (95 % CI 0.2–0.9), respectively. Conclusion Treatment with ESWL results in complete ductal clearance rate in a majority of patients, resulting in absence of pain during follow up in over half of patients with symptomatic chronic pancreatitis caused by obstructing pancreatic duct stones.

Su1521 EARLY SINGLE-OPERATOR CHOLANGIOSCOPY ASSISTED ELECTROHYDRAULIC LITHOTRIPSY (SOC-EHL) IN THE MANAGEMENT OF DIFFICULT BILIARY STONES IS COST-EFFECTIVE WHEN COMPARED TO A DELAYED STEP-UP APPROACH TO SOC-EHL

Single-operator cholangioscopy assisted electrohydraulic lithotripsy (SOC-EHL) is the current standard of care for the management of difficult bile duct stones with failed clearance using conventional endoscopic retrograde cholangiopancreatography (ERCP). This modality; however, is expensive and the optimal timing of its use, in terms of cost-effectiveness, in the management of difficult bile duct stone remains unclear. To determine the most cost-effective timing of SOC-EHL utilization in the endoscopic management of difficult common bile duct stones. Difficult stones were defined as having failed ductal clearance via standard ERCP. A decision model was developed assessing 3 strategies with progressively delayed sequences of SOC-EHL introduction in relation to initial failed ERCP, adopting a 6-month time horizon. Probability estimates for each health state were obtained from a systematic review of the literature. For each strategy, outpatients undergoing ERCP underwent different timings of SOC-EHL introduction with regards to the failed initial ERCP, and were followed for subsequent need for re-intervention, adverse events, need for surgery, and/or successful endoscopic ductal clearance. The unit of effectiveness was complete ductal clearance without need for surgery. Deterministic and probabilistic sensitivity analyses were performed varying sequentially or synchronously all 54 model variables across ranges spanning 30% of their respective values. Costs were expressed in 2018US$, based on national US data. The strategy of performing SOC-EHL at a next procedure following initial failed ERCP is the least expensive approach when compared to delaying SOC-EHL. This strategy costs US$18506 on average per patient with complete ductal clearance and save between US$390 to US$734 when compared to the other two strategies, which introduce SOC-EHL only at the second or third ERCP following the initial failed procedural attempt. Effectiveness is clinically comparable between the three strategies ranging from 97-99%. Deterministic and probabilistic sensitivity analyses show changes in the results with variations of probability assumptions but especially when varying costs of SOC-EHL, ERCP facility fees and failure rates. Although SOC-EHL is expensive, this analysis demonstrates that among patients who have failed a prior attempt at stone extraction, utilization of SOC-EHL at the first subsequent ERCP is most cost-effective when compared to its delayed introduction. The results however, can vary with changes in ERCP facility fees, the failure rates and SOC-EHL equipment costs.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2years.

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series. A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population. Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23). This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

1420 No Stone Left Unturned: Use of a Novel Device for Pancreatic Calculi Extraction

INTRODUCTION: Pancreatic calculi are found in up to 60% of patients with chronic pancreatitis and can cause pancreatic ductal obstruction and chronic pain. Previous endoscopic methods for pancreatic stone removal include blind mechanical lithotripsy with a balloon or basket, or directly visualized laser or electrohydraulic lithotripsy (EHL). However, these techniques have variable success rates with significant complications. Here we present the first use of the SpyGlass™ Retrieval Basket for extraction of pancreatic duct stones. CASE DESCRIPTION/METHODS: A 65-year-old male with compensated alcoholic cirrhosis and chronic recurrent pancreatitis was referred for evaluation of a diffusely dilated pancreatic duct (PD) seen on MRI. The patient underwent an endoscopic ultrasound (EUS) which showed a tortuous main PD dilated to 8.6 mm. Two hyperechoic foci up to 10 mm were found in the main PD suggestive of calculi. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP). Pancreatogram revealed a dilated and beaded main PD with stones in the head and neck portion of the main PD. A pancreatic sphincterotomy was performed; and the main PD was dilated and swept with a Hurricane balloon removing one stone and debris. Complete ductal clearance could not be achieved using mechanical lithotripsy with a balloon, so the patient returned for a subsequent ERCP. We then used SpyGlass™ for direct pancreatoscopy, which revealed multiple large calculi in the genu of the main PD. The SpyGlass™ Retrieval Basket was advanced through the SpyScope™ and used to manipulate, dislodge and remove the PD stones. Six stones were extracted from the duct. The patient had mild post-ERCP pain, which was treated with oral medications. DISCUSSION: The Spyglass™ Retrieval Basket is a device developed for directly visualized stone extraction through the SpyGlass™ system. In contrast to EHL or laser lithotripsy it does not require fragmentation of stones, which may reduce the risk of post-procedural pancreatitis and perforation. This is the first use of the SpyGlass™ Retrieval Basket to extract stones from the pancreatic duct.

Role of pancreatoscopy in management of pancreatic disease: A systematic review.

BACKGROUNDPer-oral pancreatoscopy (POP) plays a role in the diagnosis and therapy of pancreatic diseases. With recent technological advances, there has been renewed interest in this modality.AIMTo evaluate the efficacy and safety of POP in management of pancreatic stone disease and pancreatic ductal neoplasia.METHODSTo determine the safety and efficacy of POP in the management of pancreatic diseases, a systematic search was conducted in MEDLINE, EMBASE and Ovid. Articles in languages other than English and case reports were excluded. All published case series were eligible. Data specific to POP were extracted from studies, which combined cholangiopancreatoscopy. Ten studies were included in the analysis of POP therapy for pancreatic stone disease, and 15 case series satisfied the criteria for inclusion for the role of POP in the management of pancreatic ductal neoplasia. The examined data were subcategorized according to adjunctive modalities, such as direct tissue sampling, cytology, the role of intraoperative POP, intraductal ultrasound (IDUS) and POP combined with image-enhancing technology.RESULTSThe success rate for complete ductal stone clearance ranged from 37.5%-100%. Factors associated with failure included the presence of strictures, multiple stones and the inability to visualize the target area. Although direct visualization can identify malignant and premalignant conditions, there is significant overlap with benign diseases. Visually-directed biopsies provide a high degree of accuracy, and represent a unique approach for tissue acquisition in patients with ductal abnormalities. Addition of pancreatic fluid cytology increases diagnostic yield for indeterminate lesions. Protrusions larger than 3 mm noted on IDUS are significantly more likely to be associated with malignancy. The rate of adverse events associated with POP ranged from 0%-35%.CONCLUSIONCurrent evidence supports wider adoption of pancreatoscopy, as it is safe and effective. Improved patient selection and utilization of novel technologies may further enhance its role in managing pancreatic disease.

Multidisciplinary management of hepatilithiasis: a case series

Introduction: Hepatolithiasis is more prevalent in Far-East countries such as Korea, Japan and Taiwan than in Middle-East countries. It may be complicated by liver abscess, biliary strictures, liver cirrhosis and cholangiocarcinoma. There are various treatment modalities available for hepatolithiasis, including surgical treatments, endoscopic approaches and intervention radiological procedures. But the most efficient treatment of hepatolithiasis still remains unclear. Method: This is a retrospective study of 11 cases of hepatolithiasis who underwent multidisciplinary management from 13th April 2016 to 10th March 2019. We evaluated demography of the patients, site of hepatolithiasis, modalities of treatment, rate of ductal clearance, recurrence and mortality. Result: The age of the patients ranged from 25 to 70 yrs with female predominance (F: M = 8:3). Most of them were secondary hepatolithiasis (63.6%) and left sided (54.5%). They were treated with either surgical or intervention radiological or both procedures. Surgical procedures include left lateral sectionectomy, right hepatectomy, hepaticojejunostomy and choledocholithotomy with choledochoscopic stone extraction with T-tube placement. Intervention radiological procedures used were Percutaneous Transhepatic Biliary Drainage (PTBD), Balloon stricturoplasty and Dormia basket stone extraction. Complete ductal clearance was achieved in 7 patients (63.6%) and among them there was no recurrence. There was no mortality. Conclusion: Patients with hepatolithiasis should be treated with multimodality approaches in order to achieve the clearance of calculi, the correction of strictures, the removal of lesions and restoration of bile drainage.

A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave.

When conventional endoscopic treatment of bile duct stones is impossible or fails, advanced endoscopy-assisted lithotripsy can be performed by electrohydraulic lithotripsy (EHL), laser lithotripsy, or extracorporeal shock wave lithotripsy (ESWL). No systematic review has compared efficacy and safety between these techniques. A systematic search was performed in PubMed, the Cochrane Library, and EMBASE for studies investigating EHL, laser lithotripsy, and ESWL in patients with retained biliary tract stones. After screening 795 studies, 32 studies with 1969 patients undergoing EHL (n = 277), laser lithotripsy (n = 426) or ESWL (n = 1266) were included. No randomized studies were available. Although each advanced lithotripsy technique appeared to be highly effective, laser lithotripsy had a higher complete ductal clearance rate (95.1 %) than EHL (88.4 %) and ESWL (84.5 %; P < 0.001). In addition, a higher stone fragmentation rate was reported for laser lithotripsy (92.5 %) than for EHL (75.5 %) and ESWL (89.3 %; P < 0.001). The post-procedural complication rate was significantly higher for patients treated with EHL (13.8 %) than for patients treated with ESWL (8.4 %) or laser lithotripsy (9.6 %; P = 0.04). Data on the recurrence rate of the biliary tract stones were lacking. This systematic review revealed that laser lithotripsy appeared to be the most successful advanced endoscopy-assisted lithotripsy technique for retained biliary tract stones, although randomized studies are lacking.

Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic Stones

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 the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications. Results: Twelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.

Safety and Efficacy of Endoscopic Retrograde Cholangiopancreatography for Choledocholithiasis in Long-Term Dialysis: A Propensity Score Analysis.

Previous studies evaluating the safety of endoscopic retrograde cholangiopancreatography (ERCP) in patients with end-stage renal disease (ESRD) undergoing hemodialysis reported an increased risk of post-procedural bleeding. We investigated the safety and efficacy of ERCP for the treatment of choledocholithiasis in patients with ESRD undergoing long-term dialysis. A total of 3466 patients who underwent ERCP due to choledocholithiasis between January 2000 and Feb 2018 were reviewed and analyzed retrospectively. Patients were divided into dialysis and non-dialysis group, and propensity score matching was used to minimize selection bias. Patients of dialysis group (n = 39) and non-dialysis group (n = 78) were compared after propensity score matching. Among 39 patients of dialysis group, hemodialysis was used in 28 (71.8%) patients for renal replacement therapy, while 11 (28.2%) patients received peritoneal dialysis. The median duration of dialysis was 8years (range 1-24years). Overall success rate of ERCP was not different between two groups. The overall prevalence of post-procedural complications in dialysis group and non-dialysis group was 28.2 and 15.4%, respectively (p = 0.100). Post-procedural bleeding occurred more frequently in dialysis group than non-dialysis group (23.1 vs 5.1%, p = 0.004). All procedure-related bleeding episodes were successfully controlled using endoscopic management. Prevalence of post-ERCP pancreatitis, infection, and perforation were not significantly different between two groups (p > 0.05). Overall success rate of complete ductal clearance was not different between dialysis and non-dialysis groups. The risk of post-procedural bleeding seems to be increased in patients with ESRD undergoing long-term dialysis.