Electrohydraulic Lithotripsy Research Articles

OGBN P09 Sharing the experience of the use of Spyglass DS - guided electrohydraulic lithotripsy (SG-EHL) in the treatment of large gallstone causing Bouveret syndrome

Abstract Background Less than 1% of intestinal obstruction is accounted for by gallstone ileus. Gallstone ileus is a mechanical intestinal obstruction resulting from gallstone impaction within the gastrointestinal tract. Under 3% of gallstone ileus are caused by gallstone impaction in the duodenum or pylorus, which can give rise to a gastric outlet obstruction, described by Bouveret in 1896. Surgical intervention involves the removal of the stone by either a gastrotomy or duodenotomy, which is associated with significant morbidity. Advancement in endoscopic techniques, allows for more complex procedures, therefore, reducing the need for a surgical intervention and its accompanying morbidity. This abstract presents a rare case of a large gallstone (22mm×34mm) partially impacted in the duodenum of a 92-year-old female, which was treated with the Spyglass DS-guided electrohydraulic lithotripsy (DS-EHL). Methods A 92-year-old female with a previous history of gallstone ileus was treated by surgical intervention. The patient continued to complain of abdominal discomfort and occasional vomiting. A CT scan revealed a fistulous communication to the duodenal bulb, containing a large gall stone (22mm x34 mm). After consultation with the patient, an initial assessment with the use of standard endoscopy under general anaesthesia confirmed the visualisation of a portion of the gallstone in the duodenum, hanging through a well-established cholecysto-dudenal fistula. SPyglass DS - guided lithotripsy (SG-EHL) was used in the treatment of the large gallstone. Results Electrohydraulic lithotripsy (EHL) was attempted through the standard gastroscope, but we were unable to secure a safe position to target the stone. Therefore, a side view duodenoscope was used along with the SpyGlass DS to obtain good visualisation and stable access to target the stone with the EHL. The Spyglass guided electrohydraulic lithotripsy (SG-EHL) was used to fragment the stone. Despite consuming four EHL wires and using higher settings, we only managed to break the shell of the stone, reducing its size by approximately 3mm all around. The laser was not available at the time; therefore, the procedure was concluded. The patient had an uneventful recovery and was discharged home. No further symptoms were recorded by patient on follow up 5 months later. Conclusions Endoscopic management of an impacted gallstone causing gastric outlet obstruction is found to be safe and carries less morbidity than the traditional surgical approach. Therefore, it should be considered for being the procedure of choice to treat patients with Bouveret syndrome. Laser lithotripsy should be available on standby for cases that involve stones that are harder to break.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

A case of pancreatic duct stones treated with electrohydraulic lithotripsy through a duodenal ulcer.

Video 1Crush the large-sized stones directly using an electrohydraulic lithotripsy device.

Intractable Pancreatic Stone Removal Using SpyGlass™ DS II with Electrohydraulic Lithotripsy: A Case Report and Literature Review

Pancreatic stones are a common finding of chronic pancreatitis and may causerecurrent abdominal pain and pancreatitis. Pancreatic stones are often accompaniedby stenosis of the pancreatic duct and are often impacted within the pancreaticduct, so it is not easy to remove the pancreatic stones using a basket. Until now,extracorporeal shock wave lithotripsy has been used, but it requires repeatedprocedures and the success rate is not very high. The recently developed SpyGlass™DS II (Boston Scientific, Marlborough, MA, USA) has a 3.5 mm diameter that allowsinsertion into the dilated pancreatic duct, it is possible to remove the pancreaticstones using electrohydraulic lithotripsy (EHL) or laser lithotripsy while directlyviewing the pancreatic stones. In this paper, we would like to introduce a method toremove multiple pancreatic stones larger than 10 mm using SpyGlass™ DS II with EHL.

Single-operator Cholangioscopy Guided Lithotripsy

ERCP is the standard treatment for common bile duct stones (CBD stones). On the other hand, in approximately 10% of patients with CBD stones, the complete removal of the stones cannot be achieved by conventional ERCP, which performs endoscopic sphincterotomy followed by stone extraction. Additional advanced and complex procedures are often necessary to remove these "difficult bile duct stones", including endoscopic papillary large balloon dilatation or mechanical lithotripsy. Advances in cholangioscopy have made electrohydraulic or laser lithotripsy under direct endoscopic visualization possible during ERCP. Cholangioscopy-guided lithotripsy using the SpyGlass DS system could be a better treatment tool for removing difficult stones. The focus of this review was to describe single-operator cholangioscopy in the management of difficult CBD stones.

EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy

Video 1EUS-guided jejuno-jejunostomy in a 67-year-old male patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy.

Gel-immersion electrohydraulic lithotripsy during digital single-operator cholangioscopy is helpful when bleeding occurs.

Gel-immersion electrohydraulic lithotripsy during digital single-operator cholangioscopy is helpful when bleeding occurs.

S2838 Giant Choledocholithiasis Treated by Direct Cholangioscopy With Gastroscope and Electrohydraulic Lithotripsy

Introduction: The extraction of very large bile duct stones can pose significant challenges. In the following report, we describe the use of direct cholangioscopy with a gastroscope to facilitate electrohydraulic lithotripsy (EHL) and remove a giant common bile duct (CBD) stone. Case Description/Methods: A 71-year-old female presented to the emergency department with 3 months of intermittent right upper quadrant pain. She denied having nausea, vomiting, or loss of appetite, and physical examination was unremarkable. A CT of the abdomen and pelvis was performed, which revealed a large 9 x 4 x 4 cm hyperdense mass underneath the liver, adjacent to the gallbladder. An endoscopic ultrasound showed a very large radiopaque filing defect in a very dilated bile duct, and a cholangiogram during endoscopic retrograde cholangiopancreatography confirmed a very large stone occupying the entire CBD. To remove the stone, a biliary sphincterotomy was performed, and the bile duct orifice was dilated with a 12-15 mm balloon. Next, the duodenoscope was replaced with a standard adult gastroscope. The gastroscope was guided through the major papilla into the bile duct, and EHL was used for stone fragmentation. Large stone fragments were removed under direct visualization using a wire basket through the gastroscope. Two sessions of EHL via direct cholangioscopy with the gastroscope were required to achieve complete bile duct clearance. (Figure) Discussion: Choledocholithiasis is the presence of a gallstone in the CBD, occurring in up to 20% of patients with cholelithiasis. While smaller stones (< 1.5 cm) can often be removed intact via endoscopic sphincterotomy and sphincteroplasty, larger stones can be more difficult to remove and may require lithotripsy (mechanical, EHL or laser). In rare instances and depending on local expertise, surgery is also considered. Nevertheless, cholangioscopy using SpyGlass and EHL is the most common technique for bile duct stone fragmentation. In this case, due to the large size of the CBD and giant size of the stone, we decided to use direct cholangioscopy via a standard adult gastroscope and EHL. Scope stability and visibility within such a large bile duct was significantly superior to SpyGlass, and irrigation and suction through the gastroscope allowed for high quality EHL and removal of large debris. This technique can only be applied to bile ducts that are dilated more than 15 mm in diameter and requires advancing the gastroscope into the distal bile duct using a free-handed technique.Figure 1.: Computed tomography of the abdomen and pelvis revealing a large 9 x 4 x 4 cm bile duct stone.

S348 Creating Your Own Paths: EUS-Guided Transjejunal Gallbladder Drainage and ERCP, Cholecystoscopy, and Electrohydraulic Lithotripsy for Choledocholithiasis and Cholelithiasis in a Patient With Roux-en-Y Gastric Bypass

Introduction: Treating choledocholithiasis and cholelithiasis in patients with altered gastrointestinal anatomy is a challenge given the difficulty in accessing the biliary tract using conventional endoscopic techniques. Endoscopic ultrasound (EUS) directed transgastric ERCP (EDGE) represents a novel solution to this challenge. It allows access to the excluded stomach allowing safe performance of ERCP and interventional EUS procedures including gallbladder drainage. Case Description/Methods: A 61-year-old man with a history of morbid obesity, Roux-en-Y gastric bypass, and bowel perforation complicated by extensive resection and short gut syndrome, as well as rheumatoid arthritis and chronic kidney disease, presented to clinic for intermittent right upper quadrant pain, nausea, and vomiting. Imaging revealed large cholelithiasis, choledocholithiasis, and biliary dilatation with gallbladder distention. Given his high surgical risk and symptomatic biliary disease, EDGE and EUS-guided management of the large gallstone was planned. The first step was to create a jejunogastrostomy (JG) which was performed using EUS-guided 15mmx10mm lumen-apposing metal stent (LAMS) deployment through the Roux limb into the excluded stomach. ERCP was performed 4 weeks later finding choledocholithiasis, and complete removal of two stones was accomplished. This was followed by EUS-guided gallbladder drainage via JG and successful creation of a cholecystoduodenostomy (CDS) using the 15mmx10mm AXIOS stent system. Direct cholecystoscopy, electrohydraulic lithotripsy and removal of a large gallstone were then performed. Both LAMS from JG and CDS were removed at the end of the procedure. Follow-up upper GI series at 6 weeks showed complete closure of the jejunogastrostomy fistula. Discussion: The EDGE approach provides access to the excluded remnant stomach enabling ERCP and interventional EUS procedures such as gall bladder drainage. In this case, we demonstrate the utility of this procedure in enabling access to the gallbladder and permitting direct cholecystoscopy, electrohydraulic lithotripsy, and removal of a large symptomatic gallstone, thus avoiding long-term percutaneous drains and recurrent symptoms, in addition to the risk of cholecystitis or Mirizzi syndrome from a large gallstone. Watch the video at https://tinyurl.com/ACGAbstractS348

S1732 ERCP With Per-Oral Pancreatoscopy-Guided Laser Lithotripsy for Difficult Pancreatic Duct Stones

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and balloon/basket extraction is the first line management for symptomatic pancreatic duct (PD) stones. The risk of stone extraction failure via ERCP increases with PD stones that are >10mm, impacted, multiple stones or in a complicated location [1]. With difficult PD stones, fragmentation prior to extraction may be required. Stone fragmentation can be accomplished through extracorporeal shock wave lithotripsy (ESWL), per-oral pancreatoscopy (POP) laser lithotripsy (LL) and POP- electrohydraulic lithotripsy (EHL). We report a case of difficult PD stones successfully managed by POP-LL holmium laser. Case Description/Methods: A 48-year-old man with advanced primary sclerosing cholangitis with percutaneous biliary drainage and chronic pancreatitis presented for recurrent jaundice, right upper quadrant and midepigastric abdominal pain and pruritus. ERCP revealed the ventral PD filled with numerous stones and was swept with a balloon and 1 stone was removed. Repeat ERCP was performed 2 weeks later with balloon extraction of a few small stones and debris from the PD. The ventral duct was then explored under pancreatoscopy using Spyglass, revealing multiple stones in the head and neck of the pancreas. Lithotripsy was then accomplished using a holmium laser. No immediate nor distant post-ERCP complications were encountered. A 1-week follow up revealed resolution of abdominal pain. Discussion: The patient in our case had recurrent abdominal pain caused by pancreatic duct stones resulting in pancreatic outflow obstruction. Both attempts using ERCP with balloon sweeping were unsuccessful in complete stone extraction leading to the use of POP Spyglass with laser lithotripsy for the management of the multiple remaining stones. Direct visualization of the PD with technology like Spyglass, has shown to reduce the risk of duct injury, allows the visualization of stones that may have been missed previously, and permits confirmation of clearance of the PD (Figure). As seen in this case, POP allowed for visualization of PD stones that could not be accessed through ERCP management and used in conjunction with laser lithotripsy, the PD stones were successfully and safely fragmented. POP-LL has been shown to successfully fragment difficult to manage PD stones, as evidenced in this case and other studies, and should be considered as a useful alternative in the management of numerous PD stones and/or multiple unsuccessful ERCP attempts.Figure 1.: Laser lithotripsy with holmium laser being applied through the catheter (red arrow) to the PD stone (White arrow).

S2887 Stones, Strictures and Atrophy: Treating Sequelae of Infectious Hepatolithiasis

Introduction: Primary intrahepatic cholelithiasis has been well-associated with brown or pigmented stones and recurrent pyogenic cholangitis. However, other important potential chronic complications exist beyond cholangitis of which gastroenterologists should be aware. Case Description/Methods: We present a case of a 57 year-old man with history of diabetes who returned from a 13-month stay in Japan to be admitted to an outside facility with DKA and cholangitis. He was found to have a liver abscess and left hepatic duct stricture treated with sphincterotomy, biliary stenting via ERCP, abscess drainage, and cholecystectomy. He followed up externally for stent removal with normalization of liver chemistries however CT imaging 1 year later showed persistent left hepatic duct stricture with intrahepatic segmental dilation. He experienced no early satiety, weight loss, or jaundice. He was referred to our service for further evaluation of chronic indeterminate biliary stricture. Endoscopic ultrasound demonstrated extensive small and large left-sided hepatolithiasis (A). Cholangiography during ERCP demonstrated complete filling defect of the left intrahepatic biliary ductal system preventing selective guidewire passage. Cholangioscopy was performed with successful electrohydraulic lithotripsy (EHL) of stone burden in the left main hepatic system for selective wire passage and stenting of the left intrahepatic system with a plastic stent. Biliary epithelium appeared smooth and benign. The patient was given antibiotics with no complications. ERCP was repeated in 6 weeks with further cholangioscopy with EHL fragmentation and removal of stones in left intrahepatic ductal branches, however ductal disease remained throughout smaller distal branches of the left lobe on cholangiogram. The main duct was protected with a fully-covered metal stent and antibiotics were given. Follow-up MRI/MRCP demonstrated atrophic left liver lobe (C) in addition to our findings. Left partial hepatectomy was thus performed by Surgery for definitive therapy of the diseased lobe and the patient did well post-operatively with benign pathology. (Figure) Discussion: Even in the absence of a typical recurrent cholangitis clinical syndrome, treatment of other chronic sequelae of severe primary hepatolithiasis is important in the prevention of progression to cirrhosis. Multiple interventional endoscopic methods are available and should be utilized to establish the diagnosis and optimize therapy; which may include surgery in severe cases.Figure 1.: (A) Linear EUS view of left lobe intrahepatic cholelithiasis; (B) cholangioscopic view of intrahepatic cholelithiasis fragmented by electrohydraulic lithotripsy; (C) MRI with left lobe atrophy and hepatolithiasis.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

S1923 Abutting Percutaneous Drains Can Jeopardize Healing of Post-Cholecystectomy Bile Leaks

S2870 Successful Use of EUS-Guided Choledochoduodenostomy With LAMS in a Post-Liver Transplant Patient With Recurrent Choledocholithiasis and Cholangitis

Introduction: Biliary complications, like anastomotic stricture and cholangitis, are seen in 10-15% of orthotopic liver transplants (OLT). OLTs often require multiple endoscopic retrograde cholangiopancreatoscopy (ERCP) for recurrent disease. Endoscopic ultrasound guided choledochoduodenostomy (EUS-CD) has been effective in treatment of malignant distal biliary obstruction after failed ERCP; however, there are limited reports regarding EUS-CD in OLTs. We present a case of successful EUS-CD with lumen apposing metal stents (LAMS) in an OLT with recurrent cholangitis secondary to benign anastomotic stricture refractory to management with ERCP. Case Description/Methods: A 61-year old female with 3 OLTs (1996 and twice in 2008) for autoimmune hepatitis presented with recurrent cholangitis secondary to anastomotic biliary stricture in the setting of duct mismatch with a dilated common hepatic bile duct to 3 cm. She had recurrent choledocholithiasis measuring 3 cm despite prior mechanical and electrohydraulic lithotripsy with cholangioscopy confirmed clearance. As a result, she had undergone a total of 26 prior ERCP treatments (2012-2021). She underwent an EUS-CD with LAMS for definitive treatment. 2-weeks later, an upper endoscope was traversed through the LAMS to perform lithotripsy of remaining choledocholithiasis. At this time, the patient remains free of cholangitis for the past 8 months. (Figure) Discussion: Biliary complications, like anastomotic stricture and recurrent cholangitis, are a common occurrence in OLTs. With use of various ERCP techniques, obstructions can be removed or ameliorated. Timely treatment of cholangitis is imperative as the mortality rate is high (10-30%). With each cholangitis episode and subsequent ERCP, the cumulative procedural risk and mortality increases. EUS-CD has been demonstrated to be effective in treatment for malignant distal biliary obstruction after failed ERCP. Our patient had previously undergone 26 ERCPs and additionally was on Warfarin for pulmonary embolism putting her at very high risk for complications with additional future endoscopic procedures. This represents a case of successful use of EUS-CD with LAMS in a patient post-OLT with a significant distal common bile duct stricture which had been refractory to traditional management via ERCP. Long term studies are indicated to see if this can provide durable benefit.Figure 1.: 1A. MRI imaging demonstrating a large 3 cm choledocholithiasis within the dilated CBD, which formed as a result of bile stasis. 1B. CT coronal view demonstrating successful deployment of LAMS to complete EUS-CD. 1C. Fluoroscopic view of the standard upper scope traversing through the LAMS for definitive lithotripsy and dredging of remaining choledocholithiasis. 1D. Endoscopic view of the final LAMS placement with double pigtail plastic stents.

Removal of Giant Choledocholithiasis by Direct Cholangioscopy with Gastroscope and Electrohydraulic Lithotripsy

A 71-year-old woman presented to the emergency department with 3 months of intermittent right upper quadrant pain. Laboratory results showed a total bilirubin of 0.6 mg/dL, aspartate aminotransferase of 52 IU/L, alanine aminotransferase of 90 IU/L, and alkaline phosphatase of 239 IU/L. A computed tomography of the abdomen and pelvis was performed, which revealed a large 9 × 4 × 4 cm hyperdense mass underneath the liver, adjacent to the gallbladder (Figure A, arrowhead). An endoscopic ultrasound showed a very large radiopaque filing defect in a very dilated bile duct, and a cholangiogram during endoscopic retrograde cholangiopancreatography confirmed a very large stone occupying the entire common bile duct (Figure B, arrowheads trace stone outline).

Endoscopic treatment of Bouveret syndrome with Holmium laser lithotripsy.

Gallstone ileus is a rare condition that is seen in about 0.5 % of all cases of mechanical intestinal obstruction [1]. Furthermore, only 1 %–3 % of these patients have Bouveret syndrome, which is defined as the impaction of a large gallstone within the duodenum as a result of a cholecystoduodenal fistula [2]. Endoscopic baskets, mechanical lithotripsy, electrohydraulic lithotripsy, laser lithotripsy, and extracorporeal shockwave lithotripsy are the endoscopic treatment modalities used in Bouveret syndrome [3].

Electrohydraulic lithotripsy using peroral cholangioscopy for impaction of stent-stone complex around biliary plastic stent.

A stent-stone complex is a rare complication of long-term placement of biliary plastic stents [1] [2]. Stones form around the proximal end of the stent, making endoscopic removal of the stent difficult. Herein we report a case of successful endoscopic removal of a stent-stone complex using peroral cholangioscopy-guided electrohydraulic lithotripsy (EHL).

Unusual Case of Mirizzi Syndrome Presenting as Painless Jaundice

Patient: Male, 60-year-old Final Diagnosis: Mirizzi syndrome Symptoms: Dark stools • jaundice • painless jaundice Medication: — Clinical Procedure: ERCP with stent placement • spyglass cholangioscopy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background:Isolated painless jaundice is an uncommon presenting sign for Mirizzi syndrome, which is typically characterized by symptoms of acute or chronic cholecystitis. We report a rare case of Mirizzi syndrome with an acute onset of painless obstructive jaundice.Case Report:A 60-year-old man with an unremarkable prior medical history presented with 1 week of jaundice, dark urine, and acholic stools. His laboratory studies revealed a pattern of cholestasis with marked direct hyperbilirubinemia. Ultrasound and magnetic resonance imaging studies demonstrated intrahepatic ductal dilation and cholelithiasis, including a stone within the cystic duct. Endoscopic retrograde cholangiopancreatography with SpyGlass cholangioscopy confirmed the diagnosis of Mirizzi syndrome.Conclusions:An atypical presentation of Mirizzi syndrome should be suspected in the setting of biliary obstruction without pain. The differential diagnosis is broad and includes choledocholithiasis, ascending cholangitis, and hepatobiliary malignancy. Evaluation should include laboratory studies and biliary tract imaging. Noninvasive biliary tract imaging can help exclude malignancy and confirm ductal dilation but is not sensitive for Mirizzi syndrome. Endoscopic retrograde cholangiopancreatography can serve both diagnostic as well as therapeutic purposes via stone extraction and stent placement. SpyGlass cholangioscopy can also augment management in the form of Electrohydraulic lithotripsy. Although therapeutic biliary endoscopy can be very effective, cholecystectomy remains the definitive treatment for Mirizzi syndrome.

An international experience with single-operator cholangiopancreatoscopy in patients with altered anatomy

Background and study aims The utility of digital single- operator cholangiopancreatoscopy (D-SOCP) in surgically altered anatomy (SAA) is limited. We aimed to evaluate the technical success and safety of D-SOCP in patients SAA. Patients and methods Patients with SAA who underwent D-SOCP between February 2015 and June 2020 were retrospectively evaluated. Technical success was defined as completing the intended procedure with the use of D-SOCP. Results Thirty-five patients underwent D-SOCP (34 D-SOC, 1 D-SOP). Bilroth II was the most common type of SAA (45.7 %), followed by Whipple reconstruction (31.4 %). Twenty-three patients (65.7 %) patients had prior failed ERCP due to the presence of complex biliary stone (52.2 %). A therapeutic duodenoscope was utilized in the majority of the cases (68.6 %), while a therapeutic gastroscope (22.7 %) or adult colonoscope (8.5 %) were used in the remaining procedures. Choledocholithiasis (61.2 %) and pancreatic duct calculi (3.2 %) were the most common indications for D-SOCP. Technical success was achieved in all 35 patients (100 %) and majority (91.4 %) requiring a single session. Complex interventions included electrohydraulic or laser lithotripsy, biliary or pancreatic stent placement, stricture dilation, and target tissue biopsies. Two mild adverse events occurred (pancreatitis and transient bacteremia). Conclusions In SAA, D-SOCP is a safe and effective modality to diagnose and treat complex pancreatobiliary disorders, especially in cases where standard ERCP attempts may fail.

Cholangioscopy in Children and Adolescents: Utilization, Outcomes, and Safety.

Endoscopic retrograde cholangiopancreatography (ERCP) is increasingly utilized for management of biliary disorders in children and adolescents. Practice patterns surrounding cholangioscopy in pediatric patients, however, are largely uncharacterized. We retrospectively analyzed all ERCPs in which cholangioscopy was performed on patients 18 and under at our tertiary care children's hospital from 2015 to 2020 using our institution's paper and electronic medical record system. Patient demographics, procedure indications, interventions, and associated adverse events were analyzed. Over the study period, 307 ERCPs were performed on 282 patients at our children's hospital. Cholangioscopy was performed in 36 procedures (11.7%) using the SpyGlass cholangioscope (Boston Scientific). Antibiotics to cover biliary organisms were administered to all patients precholangioscopy. Mean patient age was 13.6 years (range 7-18 years). The 2 most common indications for cholangioscopy included electrohydraulic lithotripsy for biliary stone disease and evaluation of biliary stricture (with incidental finding of biliary web in 2 patients and retained suture material in 2 patients). Adverse events were less prevalent in patients who underwent cholangioscopy relative to those who underwent ERCP. 0/36 (0%) developed post-ERCP pancreatitis, one patient had self-limited melena (possible self-limited postsphincterotomy bleeding). Patient care was enhanced by cholangioscopy in 30/36 (83.3%) of these patients. These data attest to the safety and clinical utility of cholangioscopy in children and adolescents. Cholangioscopy was performed in just over 11% of pediatric patients who underwent ERCP at our academic medical center-rates similar to those reported in adult patients. The radiation-sparing nature of cholangioscopy, coupled with these data supporting its safety, make it particularly appealing for use in children. Further multi-institution evaluation of the utility, safety, and range of indications for cholangioscopy in other practice settings would be of great interest and help guide endoscopic care.