Endoscopic Stone Removal Research Articles

Treatment of ureteropelvic junction obstruction and urolithiasis in children with minimally invasive surgery.

Ureteropelvic Junction Obstruction (UPJO) is the most common congenital ureteral anomaly. Nowadays, according to the increasing incidence of urolithiasis, 20% of children with UPJO presents urolithiasis. Open pyeloplasty was the standard treatment before the introduction of minimally invasive surgery (MIS). Nevertheless, only scattered experiences on MIS were previously described and universal agreement on the treatment of UPJO plus urolithiasis is still missing. The study aim was to describe our experience with a series of pediatric patients affected by UPJO and urolithiasis treated with robot-assisted pyeloplasty (RAP) and endoscopic removal of stones using a flexible cystoscope and a stones basket in a singular tertiary referral center. We retrospectively reviewed our data from pediatric patients affected by UPJO and urolithiasis undergoing RAP between April 2013 and December 2019. The analysis was conducted on seven patients. All procedures were performed by one expert robotic surgeon and one endoscopic surgeon skilled in the management of urolithiasis. The mean age was 7 years (IQR 4-16). The median stone area was 77.7 mm two (IQR 50.2-148.4). Most of them (71.4%) presented preoperative symptoms. The median operative time was 110 min (IQR 104-125) with a console time of 90 (IQR 90-105). The median length of stay was 5 days (IQR 4-5). Median follow-up was 16 months (IQR 10-25). RAP with concomitant flexible ureteroscope is a safe and effective option for the simultaneous management of UPJO with urolithiasis with excellent outcomes in children.

The reasons of unsatisfactory results of extracorporeal shock wave lithotripsy in patients with ureterolithiasis

The article dedicate to the problem of failure of extracorporeal shockwave lithotripsy in patients with ureterolithiasis and reveal the changes which appear in the ureter in the location of the stone.The aim. Analysis of the results of treatment in patients, suffering ureteric stones, using the ureterolithotripsy procedure after failure extracorporeal shockwave lithotripsy.
 Materials and methods. In 137 patients with ureteric stones, whom ureterolithotripsy procedure after failure extracorporeal shockwave lithotripsy was conducted, the symptoms of the disease, the diagnostic methods value, efficacy of surgical treatment and reasons of the failure of previous method of treatment were analyzed.
 Results. In 135 patients endoscopic removal of stones has been succeeded, in 2 patients because of total obliteration of the ureter, uretero-ureteral anastomosis has been performed. If the symptoms, with are characteristic of ureterolithiasis, persists up to one week stones don’t cause significant macroscopic changes to the ureter wall. If the stone persists in the ureter longer than a week we identified local appearing of oedema. Long–term (more than two months) ureteric stone persistence increase the risk of intramucosal “ingrowth” of the calculi greatly.
 Conclusion. The URS and ESWL are high effective and minimal invasive methods of surgical intervention for patients with ureterolithiasis, guaranteeing high level of postoperative “stone free rate”. Prolongation of the stone insertion time in the ureter causes the ureteric wall changes, complicating performance of minimal invasive interventions (ureterolithotripsy and extracorporeal shock–wave lithotripsy) and reduce its efficacy.

Analysis on Microbial Profiles & Components of Bile in Patients with Recurrent CBD Stones after Endoscopic CBD Stone Removal: A Preliminary Study.

Background/Aim: Common bile duct (CBD) stone recurrence after endoscopic treatment is a major concern as a late complication. Biliary bacterial factors and biochemical factors determine the path of gallstone formation. The aim of this preliminary study was to investigate the microbial profile and components of bile in patients with and without recurrent CBD stones after endoscopic CBD stone removal. Methods: Among patients who had undergone an initial endoscopic procedure for the removal of CBD stones and were followed up for >2 years, 11 patients who experienced at least two CBD stone recurrences, six months after endoscopic retrograde cholangiopancreatography (ERCP), were categorized into the recurrence group. Nine patients without CBD recurrence events were matched. Results: Polymicrobial infections are generally seen in all patients who have biliary sphincteroplasty. Microbial richness, measured by the numbers of operational taxonomic units (OTUs), was reduced in the recurrence group. The microbial evenness was also significantly lower than in the non-recurrence group. The overall microbial communities in the recurrence group deviated from the non-recurrence group. Infection with bacteria exhibiting β-glucuronidase activity was more frequent in the recurrence group, but there was no statistical significance. In an analysis of the bile components, the bile acid concentration was higher in the non-recurrence group than in the recurrence group. However, the other metabolites were not significantly different. Conclusions: Microbiota dysbiosis and altered bacterial community assembly in bile duct and decreased bile acid in bile juice were associated with recurrence of bile duct stone.

Association of long-term endoscopic biliary stent placement with choledocholithiasis: a literature review.

Endoscopic stone removal is currently the first-line procedure for the treatment of common bile duct stones. Advances in equipment and treatment techniques have expanded the scope of application of endoscopic treatment to include stones that have previously been difficult to remove endoscopically, such as stacked stones and large stones. For the treatment of common bile duct stones in elderly patients in particular, long-term placement of a biliary stent is increasingly being selected. Although periodic stent replacement is required, some reports have stated that biliary stenting is useful in terms of treatment-associated invasiveness and the incidence of accidental complications. To date, various opinions have been presented on whether the treatment of bile duct stones should aim for complete removal of stones or adopt the biliary stenting approach. Findings in previous reports suggest that both the approach for complete stone removal and the long-term stenting approach are associated with advantages and disadvantages. In this study, we reviewed previous reports on the significance of placing a stent and implementing careful monitoring rather than stone removal in patients with bile duct stones.

Indication and surgical techniques of bypass choledochojejunostomy for intractable choledocholithiasis.

Despite development in endoscopic treatment and minimally invasive surgery for choledocholithiasis, there remains a small number of patients who require bypass Roux-en-Y choledochojejunostomy (RYCJ) because of the intractable occurrence of common bile duct (CBD) stones. We herein present the detailed procedures of open RYCJ customized for intractable choledocholithiasis. The first method is a side-to-end choledochojejunostomy with intraluminal closure of the distal CBD. This method was applied to a 79-year-old female patient who underwent endoscopic retrograde cholangiopancreatography (ERCP) more than 10 times in the past 14 years (Case No. 1). The distal CBD was explored through choledochotomy and then the distal CBD lumen was occluded with internal running sutures. A large-sized choledochojejunostomy was performed. The patient recovered uneventfully and has been doing well for the past 2 years. The second method is an end-to-end choledochojejunostomy with segmental CBD resection. It was applied to a 75-year-old male patient who underwent ERCP 9 times in the past 10 years (Case No. 2). The CBD was resected segmentally and a large-sized choledochojejunostomy was performed. The patient also recovered uneventfully and has been doing well for the past 2 years. In conclusion, the primary indication of bypass RYCJ is intractable choledocholithiasis which requires numerous sessions of endoscopic stone removal over a long period. Open RYCJ is the preferred procedure to date. If the papilla is patulous, the distal CBD should be occluded or resected to prevent reflux ascending cholangitis. We recommend to resect the intrapancreatic distal CBD if it is markedly dilated like choledochal cyst.

Recurrent Nephrolithiasis in a Patient With Hypercalcemia and Normal to Mildly Elevated Parathyroid Hormone

A 42-year-old man was referred to our stone clinic for recurrent episodes of symptomatic nephrolithiasis. Spontaneous stone passages occurred at the ages of 25, 40, and 42 years with one need for endoscopic stone removal. Calculi were composed of 100% calcium oxalate monohydrate. The patient had not taken any medication or supplements. Increased fluid intake was the only intervention for stone prevention. Metabolic work-up at presentation revealed mild hypercalcemia and normal to mildly elevated intact parathyroid hormone, even after repletion with oral 25-hydroxyvitamin D.

Risk Factors for Perforation During Endoscopic Papillary Large Balloon Dilation and Bile Duct Stone Removal.

Stone removal using endoscopic papillary large balloon dilation (EPLBD) is extremely effective. However, limited research exists regarding the risk factors for perforation of the duodenal papilla and bile duct, which may be fatal. We aimed to investigate the risk factors for perforation during EPLBD + stone removal. We included patients who underwent EPLBD + stone removal at four medical facilities between January 2008 and December 2018. We retrospectively analyzed the risk factors for perforation and their relationship between overdilation and adverse events. Overdilation was defined as a ratio of the balloon diameter to the diameter of the bile duct that exceeded 100%. The diameter of the distal bile duct was measured using the diameter of the intrapancreatic bile duct at a point 10mm toward the liver from the narrow distal segment on a cholangiogram. We included 310 patients (177 males; median age: 79years [range: 46-102years]). Perforation occurred in five patients (1.6%). Multivariate analysis indicated that no surrounding-pancreas (half or less of the circumference of the intrapancreatic bile duct was surrounded by the pancreatic parenchyma) was a significant risk factor (perforation rate: 8.3%, p = 0.011, odds ratio: 12.7 [95% confidence interval: 1.8-90.5]). No significant difference was found between the overdilation and non-overdilation groups regarding the occurrence of pancreatitis, bleeding, and cholangitis. Perforation rate in patients with no surrounding pancreas + overdilation was 16.7% (2/12). Patients with perforation underwent conservative therapy, which improved their conditions. EPLBD + stone removal should be avoided in patients with no surrounding pancreas. Overdilation is not a risk factor for adverse procedural events; however, it should be limited in patients with surrounding pancreas.

Use of peroral cholangioscopy to screen for neoplastic bile duct lesions in patients with bile duct stones (with videos)

Although cholangiocarcinomas (CCAs) can be diagnosed using several modalities, the detection of early-stage cancers remains unsatisfactory. We explored whether peroral cholangioscopy (POC) could be used to screen for neoplastic bile duct lesions including CCAs in patients with bile duct stones. Two hundred seven patients who underwent endoscopic removal of bile duct stones were enrolled between August 2010 and July 2018. The primary outcome was the detection rate of intraductal neoplastic biliary lesions by direct POC. Secondary outcomes were the technical success rates of direct POC and POC-guided forceps biopsy sampling (POC-FB), the diagnostic accuracy of the direct POC findings, adverse events, and the number needed to screen to detect a neoplastic bile duct lesion. Direct POC was successful in 199 of 207 patients (96.1%). Mild cholangitis developed in 2 patients (1.0%) and was treated conservatively. Of the 199 successfully performed POCs, 31 patients (15.6%) exhibited abnormal intraductal mucosal lesions. The technical success rate of POC-FB was 90.3% (28/31 patients). The pathologic diagnoses after POC-FB were CCAs (n= 4), intraductal papillary neoplasms of the bile duct (IPN-B) (n= 2), an adenoma with dysplasia (n= 1), and benign lesions (n= 21). Direct POC correctly distinguished non-neoplastic from neoplastic bile duct lesions in 91.6% of patients. Curative surgical resection was performed for the 5 patients with CCAs or IPN-B. The number needed to screen to detect a neoplastic bile duct lesion was 29.6. Direct POC using a dedicated, ultraslim upper endoscope usefully screens for neoplastic bile duct lesions including CCAs in selected patients with bile duct stones.

Could cholecystectomy be abandoned after removal of bile duct stones by endoscopic retrograde cholangio-pancreaticography?

Background/objectiveThe current treatment for choledocholithiasis is endoscopic common bile duct clearance followed by cholecystectomy. However, few studies have investigated whether cholecystectomy is necessary after the endoscopic removal of bile duct stones. This study aimed to determine the rate of patients without symptoms during the follow-up period after endoscopic retrograde cholangiopancreaticography (ERCP). Materials and methodsWe retrospectively analyzed data from patients with choledocholithiasis who underwent ERCP from a single centre.The patients were invited to the hospital for evaluation of symptoms during the follow-up period after ERCP. The primary outcome of this study was to determine the rate of patients with symptoms during the follow-up period after ERCP. ResultsA total of 286 patients with a median age of 57 (18–95) years old were included in the study. Of these, 195patients (68%) remained asymptomatic during the follow-up period of 18 months (1–70) after endoscopic sphincterotomy without cholecystectomy. A total of 75(50%) out of 151 patients who underwent cholecystectomy reported having symptoms after ERCP. In contrast, 119 (88%) out of 135 patients did not undergo cholecystectomy after the ERCP, remained asymptomatic during a median follow-up period of 43 months (11–70). The estimated 5-year asymptomatic rates of the patients after ERCP were 51% for the whole cohort (n = 286) according to Kaplan–Meier analysis. ConclusionMajority of patients with choledocholithiasis who did not undergo cholecystectomy after ERCP were asymptomatic during the follow-up period. Thus, cholecystectomy may be unnecessary after endoscopic sphincterotomy for bile duct stones within a midterm period.

Primary endoscopic bile duct stone removal for severe acute cholangitis: a retrospective study.

Introduction:While the Tokyo Guidelines 2018 suggest primary stone removal for mild to moderate cholangitis, a guideline for severe acute cholangitis is not mentioned. We, therefore, investigated the clinical outcomes of patients with severe acute cholangitis to confirm the usefulness and safety of primary stone removal.Method:This study included 104 severe acute cholangitis patients without gallstone pancreatitis diagnosed at our institution between January 2014 and December 2020. Patients with percutaneous transhepatic biliary drainage as the primary drainage, bile duct stenosis, and endoscopically unidentified bile duct stones were excluded from this study. The clinical results of 14 patients with primary stone removal (primary group) and 23 patients with elective stone removal (elective group) were then retrospectively examined (excluding abnormal values due to underlying diseases).Results:Upon comparing the patient characteristics between groups, the elective group had significantly higher cardiovascular dysfunction (57% vs 7%; p = 0.004), septic shock (39% vs 0%; p = 0.006), disseminated intravascular coagulation treatment (57% vs 14%; p = 0.016), and positive blood cultures (91% vs 43%; p = 0.006) than those in the primary group. Endoscopic sphincterotomy for naïve papilla (90% vs 21%; p = 0.01) and endoscopic nasobiliary drainage (50% vs 9%; p = 0.014) were higher in the primary group, while endoscopic biliary stenting (7% vs 87%; p < 0.001) was lower than that in the elective group.Discussion:There were no significant differences in adverse events or complete stone removal rates between the two groups. In the primary group, the period from the first endoscopic retrograde cholangiopancreatography to stone removal (0 days vs 12 days; p < 0.001) and hospitalization period (12 days vs 26 days; p = 0.012) were significantly shorter and the hospitalization cost ($7731 vs $18758; p < 0.001) was significantly lower than those in the elective group.Conclusion:If patients are appropriately selected, bile duct stones may be safely removed for the treatment of severe acute cholangitis.

Multidisciplinary Approach to Acute Cholecystitis in a Severely Cardiopathic Patient: Case Report and Review of Literature on Treatment Strategies

Acute cholecystitis in severely cardiopathic patients after major cardiac surgery represents a challenge for surgeons. Treatment with cholecystostomy, may offer a chance to these patients, however there is still a number of controversial issues on the topic: performance surgical techniques (transhepatic or transpapillary), optimal duration and timing of drain removal, the need for further tests before removal as well as the timing for definitive surgery. We therefore deemed it important to share our experience of a multidisciplinary approach for the definitive treatment of this patient with severe heart disease. A percutaneous cholecystostomy was the chosen strategy for a 58-year-old cardiopathic patient who had undergone surgery for hip replacement and had developed acute calculous cholecystitis a few days after surgery. Two weeks after discharge, a cholangiography through the cholecystostomy and an MRI cholangiopancreatography revealed the presence of stones in the cystic duct and in the ductus choledochus. The definitive treatment was decided after consulting with a multidisciplinary team. The choice was to perform an open cholecystectomy with simultaneous removal of the cholecystostomy, endoscopic removal of stones and sphincterotomy of the Oddi papilla. Currently, the patient is healthy and his heart function satisfactory. Although early cholecystectomy is the recommended choice for acute cholecystitis, a patient with severe co-morbidities may benefit from a bridging therapy before definitive surgery and a multidisciplinary approach can provide a safer solution.

Correction: A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal.

Correction: A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal.

Efficacy of a modified short fully covered self-expandable metal stent for perihilar benign biliary strictures.

Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self-expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent-induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. Patients with perihilar BBS within 2cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5-6months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow-up period were measured. Endoscopic intraductal placement was technically successful in all patients (n=19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163days (range, 138-196days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow-up period (median 635days) after stent removal, only one recurrence developed. Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution.

SC94 - Ureteropelvic Junction Obstruction with urolithiasis: experience from a single tertiary referral center of robotic assisted pyeloplasty with endoscopic removal of stones

SC94 - Ureteropelvic Junction Obstruction with urolithiasis: experience from a single tertiary referral center of robotic assisted pyeloplasty with endoscopic removal of stones

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones.

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Effect of stent placement on stone recurrence and post-procedural cholangitis after endoscopic removal of common bile duct stones.

Background/AimsAfter endoscopic treatment of common bile duct (CBD) stones, recurrence of choledocholithiasis due to small stone fragments and post-endoscopic retrograde cholangiopancreatography (post-ERCP) cholangitis can occur. We determined the effect of biliary stenting after removal of CBD stones on the recurrence of CBD stones and the incidence of post-ERCP cholangitis. MethodsWe performed a retrospective single-center study involving 483 patients who underwent ERCP for the removal of CBD stones. The patients were classified into two groups according to their biliary stenting status. The primary outcome was the rate of CBD stone recurrence and the secondary outcome was the incidence of post-ERCP cholangitis. ResultsAmong the 483 patients, 219 and 264 did and did not receive a biliary stent after CBD stone removal, respectively. The incidence of stone recurrence was 15.5% and 7.6% in the non-stenting and stenting groups (p = 0.006), respectively, while the incidence of post-ERCP cholangitis was 4.6% and 2.7% (p = 0.256). In a multivariate analysis, biliary stenting significantly reduced the stone recurrence rate (odds ratio, 0.30; p = 0.004). ConclusionsBiliary stenting after the removal of CBD stones reduces the stone recurrence rate and assisted recovery. For patients with large and multiple stones who undergo lithotripsy, preventive biliary stent insertion can reduce the rate of stone recurrence.

Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal

BackgroundRecent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP.MethodsWe retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP.ResultsThe rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19–9.88; P = 0.02).ConclusionsWhen removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10mm, cholesterol stone, maximum diameter of CBD >15mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10mm, and EML were related to postoperative CBD stones after cholecystectomy. Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Su1585 EFFICACY OF ENDOSCOPIC MANAGEMENT FOR CONFLUENCE STONES

Confluence stone (CS), which causes type II Mirizzi syndrome, has considered to be difficult to treat endoscopically. Endoscopic treatment of CS with lithotripsy has been reported, however, its feasibility is still unclear. To examine the clinical outcomes of endoscopic removal of CS. Patients who underwent endoscopic treatment for CS in our hospital from April 2010 to March 2019 were analyzed retrospectively. The biliary stone which between common bile duct and cystic duct was considered as CS. The strategy of CS removal is as follows; endoscopic stone extraction using balloon/basket catheter and/or mechanical lithotripsy (EML) was tried initially; in casae without successful stone removal, lithotripsy, such as extracorporeal shock wave lithotripsy (ESWL) or electrohydraulic lithotripsy (EHL), was conducted before endoscopic removal. The measured outcomes were complete stone clearance rate and adverse event. A total of 21 consecutive patients (14 males and 7 females; median 65 years old) with CS were included in the study. The median CBD diameter and stone size were 9 mm (4-14 mm) and 10 mm (7-17 mm), respectively, and comorbid bile duct stone was present in 2 patients. Before the initial trial of endoscopic CD removal, 9 and 2 patients underwent endoscopic sphincterotomy (EST) and endoscopic papillary large balloon dilation (EPLBD), respectively. Endoscopic stone removal without ESWL/EHL were achieved in 6 (28.6%) patients, and the median procedureal time was 27 (range, 7-77) min. The devices used for CD extraction were balloon catheter in 6, basket catheter in 9, and EML in 12. Among 15 patients of failed CD extraction, 14 patients underwent ESWL. The median number of session and pulse were 1 (1-4) time and 5000 shots per a session. After ESWL, CD extraction was achieved in all cases. Meanwhile, another patient underwent EHL, and complete stone removal was obtained after 829 shots. No adverse event was observed. Although CS removal under endoscopic treatment alone is difficult, endoscopic CS removal is feasible and safe with ESWL or EHL.

Single‐stage retrograde endoscopic common bile duct stone removal might be sufficient in moderate acute cholangitis with a stone size ≤12 mm: A retrospective cohort study with propensity score matching

AbstractStudies elucidating the efficacy and safety of single‐stage endoscopic treatment for acute moderate cholangitis with choledocholithiasis are limited. Therefore, we performed a retrospective analysis of single‐stage endoscopic treatment for common bile duct (CBD) stone removal in patients with moderate cholangitis to determine the rates of successful stone extraction and complications. A retrospective chart review was conducted for all consecutive patients (n = 632) undergoing endoscopic retrograde cholangiopancreatography (ERCP) for CBD stone removal between January 2010 and September 2013 at the study institution. A total of 346 patients excluded based on the following criteria: procedural failure requiring an anatomy‐modifying operation, stenosis of the pyloric ring, tumor‐related obstruction, treatment requiring only biliary drainage, failure to locate the papilla, intolerance due to inadequate sedation, CBD stone &gt; 12 mm, CBD sludge, and non‐naïve papilla in ERCP. The remaining 286 patients were randomly matched at a 1:2 ratio using propensity score together with age and sex with the Number Cruncher Statistical System statistical software. After propensity score matching, there were 90 and 134 patients in the moderate and no/mild cholangitis groups, respectively. The baseline characteristics and endoscopic findings were comparable between the two groups. The success rate of complete stone extraction was similar between the moderate and no/mild cholangitis groups (90.0% vs 91.0%, P = .793). Additionally, the complication rates were comparable between the moderate and no/mild cholangitis groups (post‐ERCP pancreatitis, 13.3% vs 10.4%, P = .542; pneumonia, 4.4% vs 1.5%, P = .183; perforation, 0% vs 1.5%, P = .243; and mortality, 2.2% vs 0.7%, P = .350). However, there was a trend for higher bleeding rate in the moderate cholangitis group compared with the no/mild cholangitis group (2.2% vs 0%, P = .084). Single‐stage retrograde endoscopic CBD stone removal in patients with moderate cholangitis and choledocholithiasis sized ≤12 mm might be adequate based on the high success rate (90.0%) for stone removal and low complication rates.