Large CBD Stones Research Articles

OGBN O09V Multi-modal Approach with Fluorescence Imaging, Intraoperative Ultrasound and Laser Lithotripsy in the Laparoscopic Management of Complex Large Bile Duct Stones

Abstract Background Choledocholithiasis is a common condition with various presentations. There are several approaches through which this can be managed. This presentation aims to explain novel techniques and various modalities in managing complex bile duct stones successfully with minimal invasive approach. Methods This video presentation depicts the procedure performed for large CBD stones with the use of indocyanine green (ICG) and intraoperative ultrasound (IOUS). The patient is a 61 year old gentleman presented with abdominal discomfort and deranged liver functions. Cross sectional imaging showed 2 large CBD calculi and attempt at endoscopic retrograde cholangio-pancreatigoraphy (ERCP) failed due to large impacted stones. Decision was made to proceed to single stage laparoscopic cholecystectomy and common bile duct exploration with use of ICG, IOUS and laser lithotripsy to achieve successful clearance of CBD. Results At laparoscopy, the CBD and common hepatic artery were identified with ICG and IOUS. A vertical choledochotomy was performed and choledochoscopy undertaken. Attempts to retrieve the stone with extraction basket were not successful. Laser lithotripsy was used to break the stones into smaller fragments which were subsequently retrieved using atraumatic graspers and extraction wire. Post operative period was uneventful and the patient was discharged home on day 2. Face to face follow-up at 6 weeks confirmed good recovery. Conclusions Laparoscopic management of complex CBD stones is challenging. Despite advances in endoscopy intervention, the role of surgery is irrefutable. Advanced laparoscopic skills and experience in bile duct exploration with advanced minimally invasive instruments and equipment are critical to achieve optimal patient outcomes, and mitigated the chances of conversion to open surgery which its associated morbidity. This presentation demonstrates a safe technique while working in the hostile area of the inflamed hepatocystic triangle and an alternative method in the retrieval of large common bile duct stones following failed ERCP.

Laparoscopic CBD Exploration (LCBDE) a better and safe option for large CBD stones

Background: Conventionally, common bile duct stones (CBDS) are removed with help of ERCP. However, if CBDS are larger than 10 mm, then the ERCP failure rate to retrieve CBDS becomes high. In that case, open or laparoscopic common bile duct exploration (LCBDE) is other alternative. In this era of minimally invasive surgery, laparoscopic CBD exploration (LCBDE) seems to be a better option than open approach, but in our set up the safety of LCBDE is questioned. Aim: To see the conversion rate as well as complications associated with LCBDE. Material & Methods: Methods: This is a retrospective analysis of data of patients who underwent Laparoscopic Common Bile Duct Exploration (LCBDE) for large CBD stones at Fatima Memorial Hospital Lahore. Results: Since 2012, 29 patients of large (≥10 mm) CBD stones were included in this study. Among them 20(69.9%) were females and 9(31.01%) were males. The mean CBD stone size was 13 mm. Stones were extracted transcystically in 4 case and Transcholedochal stone extraction was done in 25 cases. The average duration of surgery was 130 minutes, but all cases were completed successfully without converting to open approach. There was minor bile leak in 3 patients which was managed successfully without any further intervention. No other complication was observed with LCBDE and even no retained stone was reported. Conclusion: Laparoscopic CBD exploration is safe and effective method of dealing CBD stones especially of large size when the chances of ERCP failure to retrieve stones are high. Keywords: Laparoscopy, ERCP, common bile duct,

A case report of spontaneous passage of large (>1.5 cm) common bile duct calculi (4 in number) through faeces

Gallbladder (GB) stones are commonly associated with common bile duct stones (CBDS). While they may remain asymptomatic, some may present with symptoms like biliary colic, jaundice and cholecystitis. Most of these stones in the CBD, if small, pass through faeces. Passing larger stones through faeces is relatively rare and if it does occur, is usually associated with fatal complications like acute pancreatitis. The authors reported a case wherein symptomatic large CBD stones were spontaneously passed through faeces and the patient was relieved of the symptoms and did not suffer any further complications. Choledocholithiasis is usually managed by endoscopic retrograde cholangiopancreatography or by laparoscopic or open choledocholithotomy. Spontaneous passage of small CBD and GB calculi through faeces although common is associated often with the development of pancreatitis. Passage of large CBD calculi (size >1.5 cm) through faeces is rarely seen.

Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study.

ObjectivesFor complicated common bile duct stones (CBDS) that cannot be extracted by endoscopic retrograde cholangiopancreatography (ERCP), management can be safely by open or laparoscopic CBD exploration (CBDE). The study aimed to assess these surgical procedures after endoscopic failure.MethodsWe analyzed 85 patients underwent surgical management of difficult CBDS after ERCP failure, in the period from 2013 to 2018.ResultsSixty-seven (78.8%) and 18(21.2%) of our patients underwent single and multiple ERCP sessions respectively. An impacted large stone was the most frequent cause of ERCP failure (60%). Laparoscopic CBDE(LCBDE), open CBDE(OCBDE) and the converted cases were 24.7% (n = 21), 70.6% (n = 60), and 4.7% (n = 4) respectively. Stone clearance rate post LCBDE and OCBDE reached 95.2% and 95% respectively, Eleven (12.9%) of our patients had postoperative complications without mortality. By comparing LCBDE and OCBDE; there was a significant association between the former and longer operative time. On comparing, T-tube and 1ry CBD closure in both OCBDE and LCBDE, there was significantly longer operative time, and post-operative hospital stays in the former. Furthermore, in OCBDE group, choledocoscopy had an independent direction to 1ry CBD repair and significant association with higher stone clearance rate, shorter operative time, and post-operative hospital stay.ConclusionLarge difficult CBDS can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, Open choledocoscopy has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and post-operative hospital stay.

Surgical (open and laparoscopic) Management of large difficult CBD stones after different sessions of endoscopic failure

Objectives: For difficult CBD stones that cannot be extracted by ERCP, patients can be managed CBD exploration. The aim of this study was to assess these surgical procedures after endoscopic failure. Methods: We retrospectively analyzed 85 patients underwent surgical management of difficult CBD stones after ERCP failure, in the period from mid 2013 to mid 2018. Results: There was significant correlation between number of ERCP sessions and post ERCP complications (P = 0.001). Impacted large stone was the most frequent cause of ERCP failure (60%). LCBDE and OCBDE were 29.4% (n = 25) and 70.6% (n = 60) respectively. Primary CBD repair, T-tube insertion, HJ and TDS were done in 45.9%, 40%, 8.3% and 5.9% respectively. By comparing LCBDE and OCBDE groups, patient age and hospital stay were significantly lower in laparoscopic group, while, T-tube insertion, choledocoscope use, operative time and post operative bile leak were significantly higher. Furthermore, patients underwent choledocoscope had significant direction to primary CBD repair and lower missed stones rate. While, on comparing T-tube with primary closure of CBD groups, there was significant lower operative time and hospital stay in the later. Conclusion: Difficult CBD stones can be managed either by open surgery or laparoscopically with acceptable comparable outcomes with no need for multiple ERCP sessions due to their related morbidities; furthermore, choledocoscope has a good impact on stone clearance rate with direction towards doing primary repair that is better than T-tube regarding operative time and hospital stay.

Laparoscopic-Assisted ERCP Rendezvous Procedure for Choledocholithiasis in Patient With Esophageal Stricture

A 65-year old male with prior laryngeal cancer with radiation-induced esophageal stricture presented with abdominal pain. CT demonstrated a 1.3cm dilated lower CBD with stones, which was confirmed by MRCP. Standard ERCP could not be performed due to esophageal stricture. Given this, a decision was made to proceed with laparoscopic-assisted ERCP. The patient was taken to the OR, where he first underwent laparoscopic cholecystectomy. Subsequently, gastrotomy with 14 mm trocar placement was performed, through which the ERCP scope was introduced. Multiple attempts to cannulate the ampulla were made but due to a very distal position of the ampulla in the duodenum attempts were unsuccessful. Thus,the decision was made to remove the cholecystectomy clips and to attempt an intraoperative rendezvous procedure. A 0.035 guidewire was inserted using laparoscopic techniques through the cystic duct into the bile duct and eventually into the duodenum. The guidewire was grasped with rat tooth forceps by a gastroscope and brought out through the gastrostomy port. The duodenoscope was backloaded over the wire and bile duct access was then easily achieved. Sphincterotomy and balloon sphincteroplasty were performed, with retrieval of two large CBD stones. Patient tolerated the procedure without complications. Technique Highlights: ERCP is commonly used in the treatment of biliary disorders in patients with normal abdominal anatomy. However, in patients with altered anatomy, particularly those who have undergone Roux-en-Y gastric bypass, this method may be challenging. Several alternative techniques have involved the use of balloon enteroscopy or laparoscopy to facilitate access to the duodenum. Studies have shown higher success rates with laparoscopic assisted approaches. Laparoscopic-assisted ERCP allows access to the duodenum through a surgical gastrotomy. In cases, such as presented here, where cannulation remains difficult, a unique “rendezvous” technique can be attempted if surgical clips are removed. In this case, precut was avoided and hence exposing the patient to increased risk of bleeding and pancreatitis.

Treatment of Large CBD Stones Using Endoscopic Ultrasound (EUS)-Directed Transgastric ERCP (EDGE) in Patients With Roux-en-Y Gastric Bypass

Treatment of Large CBD Stones Using Endoscopic Ultrasound (EUS)-Directed Transgastric ERCP (EDGE) in Patients With Roux-en-Y Gastric Bypass

Peroral direct cholangioscopy using an ultra–slim gastroscopy assisted by a snare

Objective To evaluate the feasibility of diagnostic and therapeutic peroral direct cholangioscopy (PDCS) using an ultra–slim upper endoscopy assisted by a snare. Methods Between November 2014 and January 2015, 8 patients underwent PDCS with assistance of an ultra–slim endoscopy. After endoscopic papillary balloon dilation, the duodenoscopy was withdrew, an ultra–slim endoscopy was inserted directly into the biliary tract assisted by a snare, and biopsy or laser lithotripsy was performed. The snare was closed tightly in the bent portion of the scope, and the snare was pulled while scope shaft had to become the form of U loop by counterclockwise rotation, in order to advance the scope into common bile duct. Results PDCS succeeded in all eight cases, one common hepatic duct adenoma was diagnosed by biopsy, and confirmed by surgery; one benign biliary stricture was diagnosed by PDCS; laser lithotripsy was successfully performed in 4 patients with large CBD stones; bile duct clearance was verified by PDCS in two patients who was suspected of residual CBD stones. No perforation, bleeding or post–operative pancreatitis was found. Conclusion PDCS using an ultra–slim gastroscopy assisted by a snare is a safe, simple and practical procedure in the diagnosis and treatment of biliary tract diseases. Key words: Biliary tract diseases; Choledocholithiasis; Gastroscopes; Lithotripsy, laser; Peroral direct cholangioscopy

Management of Obstractive Jaundice Due to Common Bile Duct Stone in Baghdad Teaching Hospital.

Background: the most common cause of obstructive jaundice is CBD stones, and these can produce significant morbidity and mortality. The management of the obstructive jaundice due to CBD stones is in evolution; several methods of investigations and treatment have been introduced, and each one has its own advantages and disadvantages.
 Objective: to study and evaluate the management of obstructive jaundice due to CBD stones in Baghdad teaching hospital.
 Results: from the 125 patients presented with obstructive jaundice included in this study 14 patients were found to have a periampullary lesions, and they were excluded from the study, so the total number of the patients was 111; 46 males and 65 females Endoscopic management was done for 108 patients with success rate of 90%. Surgical treatment was required in 13 patients, 10 of them following failure of ERCP and the other 3 patients were those with Mirizzi syndrome. The most common complication of ERCP was acute pancreatitis and the most common cause of failure to extract the stones was the size of stone (more than 15mm)Patients and methods: a prospective study of 111 patients with clinical, laboratory, and imaging features suggestive of obstructive jaundice due to CBD stones who were managed in Baghdad teaching hospital over the period from January 2011 to November 2011; other 14 patients with obstructive jaundice due to other causes were excluded. . All patients were symptomatic and had abnormal liver function tests. Transabdominal US was done for all of them, MRCP for 26 patients, and EUS for 9 patients. Four patients had primary stones, 95 patients had secondary stones, 9 patients had retained stones and 3 patients had Mirizzi syndrome.Those patients were subjected to ERCP both to prove the diagnosis and extract the CBD stones. Only three patients sent directly for surgical treatment because they were diagnosed as Mirizzi syndrome. Surgical treatment also was offered for those patients in whom endoscopic management failed. 
 Conclusions: Endoscopic sphincterotomy and stone extraction followed by laparoscopic
 cholecystectomy is still considered the orthodox treatment of CBD stones. Large and multiple CBD stones are the most common causes of failure of endoscopic extraction and indication for surgical treatment. There was higher incidence of retained CBD stones in our study than what was reported in western countries, because there is no intraoperative screening to avoid missing CBD stones in our hospital.

PTH-008 Safety And Efficacy Of Balloon Sphincteroplasty Using Controlled Radial Expansion (cre) Balloon During Endoscopic Retrograde Cholangio Pancreatography In The Management Of Large Common Bile Duct (cbd) Stones: A District General Hospital Experience

IntroductionExtraction of large (>1 cm) CBD stones at ERCP is often difficult despite adequate sphincterotomy. Failure of extraction of stones warrants repeat ERCPs and also referral to advanced techniques such...

Safely Stretching Our Options for Removing Large CBD Stones

In 10–15 % of endoscopic retrograde cholangiopancreatography (ERCP) procedures performed for the indication of suspected choledocholithiasis, identified stones can be difficult to remove [1]. Common factors associated with failure include stones[1 cm, numerous stones, and altered biliary anatomy. There are several techniques for removing these ‘‘difficult CBD stones’’. Leaving a plastic biliary stent in place with or without ursodeoxycholic acid therapy with subsequent ERCP is often successful [2]. Mechanical lithotripsy (ML) fragmentation combined with biliary sphincterotomy (EST) successfully removes many large stones [3, 4]. Complications following biliary sphincterotomy and ML include bleeding, pancreatitis, and perforation and are usually mild and self-limited but on rare occasions can cause short-term morbidity or even death [5]. Electrohydraulic lithotripsy can be useful for disintegrating stones prior to removal, but requires direct visualization of the stone with cholangioscopy with attendant risks such as hemobilia, cholangitis, and ductal perforation [6]. Endoscopic papillary balloon dilation (EPBD), or balloon sphincteroplasty, has evolved as another technique for removing large bile duct stones. Controlled radial expansion (CRE) balloons 6–10 mm in diameter stretch the intact sphincter of Oddi to facilitate stone removal. Though early experience with balloon sphincteroplasty was promising, subsequent multicenter, randomized controlled trials reported overall higher rates of pancreatitis including severe pancreatitis leading to death in some patients treated with balloon sphincteroplasty [7, 8]. While balloon sphincteroplasty remains an accepted practice in some parts of the world, the American Society for Gastrointestinal Endoscopy only recommends EPBD for patients in whom sphincterotomy is considered too risky or difficult such as patients medically anticoagulated or those with post-surgical anatomy or a periampullary diverticulum [1]. Endoscopic papillary large-balloon dilation (EPLBD) is a technique introduced in 2003 that dilates with a 12 to 20-mm CRE balloon following biliary sphincterotomy [9]. Balloon size is chosen to be at least the same diameter as the stone but no larger than the diameter of the bile duct. The initial published retrospective series reported that biliary stones too large to be removed despite a complete sphincterotomy and use of an extraction balloon or basket could be successfully removed in most cases without the use of ML [9]. Furthermore, the overall complication rate was an acceptable 15.5 %, consisting of mild-to-moderate cholangitis, pancreatitis, and bleeding, with no deaths [9]. Several retrospective studies, prospective series, and randomized controlled studies have reported that EPLBD is an effective and mostly safe method for the removal of large CBD stones [10–16]. A recent systematic review of R. Daniel Lawson: A military service member (or employee of the U.S. Government).

Electrohydraulic lithotripsy as an highly effective method for complete large common bile duct stone clearance

The removal of common bile duct (cBD) stones is commonly performed by endoscopic retrograde cholangiography (eRc), which has an 85-90% success rate. Thus, 10-15% of cBD stones, specifically large ones, cannot be completely removed using standard techniques and are therefore managed conservatively by sequential biliary stenting or using other techniques such as electrohydraulic lithotripsy (ehL). The aim of the present paper was to determine the outcomes of these different methods for the removal of large cBD stones in the patients who failed to clear the cBD after initial attempt and to identify the factors which might associated with patients who would fail for sequential biliary stenting. We retrospectively reviewed 439 patients who underwent eRc for stone removal in our institute. In this study, 36 cases and 7 cases were included in the sequential biliary stenting and intraductal ehL groups, respectively, with rates of complete cBD clearance of 86.1% and 100%, respectively. On average, 2.8 and 1.3 sessions were required before complete stone removal in the biliary stenting and ehL groups, respectively. The number of complications during follow-up was higher in biliary stenting than in intraductal ehL patients. The factors associated with failure to complete cBD stone clearance in the biliary stenting group were no change in cBD stone size 9 weeks after the first biliary stenting attempt and failure of balloon sphincteroplasty. ehL was an effective and safe procedure for acheivement of complete cBD clearance especially for large cBD stone.

One-Step Transpapillary Balloon Dilation under Cap-Fitted Endoscopy without a Preceding Sphincterotomy for the Removal of Bile Duct Stones in Billroth II Gastrectomy

Background/AimsEndoscopic sphincterotomy may be limited in Billroth II gastrectomy because of difficulty in orientating the duodenoscope and sphincterotome as a result of altered anatomy. This study was planned to investigate the efficacy and safety of endoscopic transpapillary large balloon dilation (EPBD) without preceding sphincterotomy for removal of large CBD stones in Billroth II gastrectomy.MethodsBetween March 2010 and February 2011, one-step EPBD under cap-fitted forward-viewing endoscopy was performed in patients who had undergone Billroth II gastrectomy at two tertiary referral centers. Main outcome measurements were successful duct clearance and EPBD-related complications.ResultsSuccessful access to major duodenal papilla was performed in 13 patients, but successful selective CBD cannulation was achieved in 12 patients (92.3%). Median maximum transverse stone size was 11.5 mm (10 to 14 mm). The mean number of stones was 2 (1-5). The median CBD diameter was 15 mm (12 to 19 mm). Mean procedure time from successful biliary access to complete stone removal was 17.8 min. Complete duct clearance was achieved in all patients. Four patients (33.3%) needed one more session of ERCP for removal of remnant stones. Asymptomatic hyperamylasemia in two patients and minor bleeding in another occurred.ConclusionsWithout preceding sphincterotomy, one-step EPBD (≥10 mm) under cap-fitted forward-viewing endoscopy may be safe and effective for the removal of large stones (≥10 mm) with CBD dilatation in Billroth II gastrectomy.

Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: Efficacy and analysis of factors that favor stone fragmentation

Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study. A total of 283 patients with large CBD stones were subjected to ESWL. A maximum of 5000 shocks was delivered per session until CBD stones were fragmented to less than 5 mm diameter. CBD was cleared by biliary endotherapy using a basket or balloon. Outcome was assessed by CBD clearance. Total CBD clearance was achieved in 239 patients (84.4%) and partial CBD clearance in 35 patients (12.3%). Three or fewer sessions of ESWL were required in 74.6% of patients. Minor complications were seen in 45 patients (15.9%). There was no procedure-related mortality. Epidural anesthesia, shock frequency of 90/min, radiolucent calculi and presence of fluid around the calculus helped in better fragmentation. A high success rate, negligible complications and non-invasive nature of the procedure make ESWL a useful tool for removing large CBD stones.

The Effect of Biliary Stenting with Combined UDCA and Rowachol Administration On Retained CBD Stones -Multicenter Study-

Background & Aim: Endoscopic sphincterotomy and stone extraction is effective treatment of choice for patients with CBD stones. Endoscopic biliary stenting is one of the palliative treatment for the patients with impacted large CBD stones. Long-term treatment with biliary stenting can decrease the size of stone. Choleretic agents, UDCA and Rowachol, may enhance the dissolution of gallstones. We studied the effectiveness of a period of biliary stenting combined with UDCA and Rowachol administration as a medical treatment for difficult CBD stones. Patients & method: Between October 2005 and September 2007, a total of 21 patients (7 men; mean age; 71.5 years) with CBD stones failed on endoscopic removal including mechanical lithotripsy were enrolled. After trying endoscopic stone removal, we had placed 10F plastic stent above the top of stone, and medicated UDCA (600 mg) and Rowachol (300 mg) a day for 6 months (range: 3∼13). At 6 months of medication after initial ERCP or when stent was invisible during follow up, second ERCP was performed. The stone size and CBD diameter before and after stent insertion was compared and endoscopic stone removal was re-tried. Statistical analysis was done by Wilcoxon signed rank test. Result: Initial mean diameters (transverse × longitudinal) of CBD stones were 19.4 × 28.6 mm and decreased to 12.2 × 20.9 mm at 2nd ERCP after biliary stenting with medication (p < 0.05). Mean diameter of CBD measured at cystic duct insertion level was 22.6 mm and also decreased to 19.9 mm after biliary stenting with medication. Endoscopic stone removal was successful in 19 of 21 patients (90.4%) with mean 1.5 sessions of ERCP. Conclusion: The endoscopic biliary stenting with a period of combined UDCA and Rowachol administration for difficult CBD stones seems to be an effective and safe method as a medical treatment. For more significant results, a randomized, prospective study will be required.

A Single Institutionʼs Initial Experience with Spyglass™ in the Diagnosis and Management of Biliary Disease during ERCP

Purpose: To evaluate the clinical utility, safety and ease of use of SpyGlass™ (a single-operator peroral cholangiopancreatoscopy system) during endoscopic retrograde cholangiopancreotography (ERCP). Methods: A retrospective chart review was performed of the ERCP cases during which Spyglass™ was used. For each case, the following outcomes were assessed: success of introducing the device into the bile duct; successful identification of filling defects; use and success of electrohydraulic lithotripsy (if performed); use and success of directly visualized forceps biopsies; and yield of biopsies. Results: Spyglass™ cholangiopancreatoscopy was attempted in 6 patients. A single operator performed each case. Indications for Spyglass™ included: unexplained abdominal pain of suspected biliary origin (N = 1) and filling defects seen on initial cholangiogram [suspected choledocolithiasias (N = 3) and malignant stricture (N = 2)]. Cannulation with Spyglass™ was successful in 5 of 6 patients (83.3%). The single failed cannulation was due to difficult anatomy from a suspected malignant biliary stricture in the distal common bile duct. Identification of filling defects was achieved in 4 of the 5 successful cannulations (3 with stones, 1 with malignancy). Biopsies were performed in 1 case with a successful diagnosis of a ductal carcinoma. Therapy using electrohydraulic lithotripsy (EHL) via the Spyglass™ device was attempted in 2 patients (1 with a common bile duct stone, 1 with a cystic duct stone). Partial clearance was achieved in each case. Failure of successful lithotripsy was due to (1) the size of the common bile duct stone and (2) inability to maintain good stone to EHL probe contact in the cystic duct. No procedure related complications occurred. Conclusion: In this small retrospective review, the Spyglass system demonstrated adequate visualization of the biliary tree to facilitate the diagnosis of biliary strictures and lithotripsy of large CBD stones during ERCP. Further investigation to identify the optimum patient characteristics for cholangiopancreatoscopy with this system is required and ongoing.

Utility of the SPYGLASS Cholangiopancreatoscope (SCPS): An Initial Series of 26 Cases at a Tertiary Care Center

Purpose: The SCPS is a recent innovation in which a single endoscopist is able to perform cholangiopancreatoscopy. The clinical utility of this new device has not been well studied. The goal of our study was to review our initial experience with the SCPS and assess its usefulness as a diagnostic and therapeutic tool. Methods: We retrospectively examined 26 cases using SPCS. All procedures were performed by one of three biliary endoscopist with experience in cholangioscopy. Success in imaging the desired ductal structures, in performing electrohydraulic lithotripy (EHL), and in guiding biopsy was assessed. Results: In 20 cases cholangioscopy utilized the Spyscope catheter and in 6 cases the SPYGLASS video fiber was passed through a triple lumen sphincterotome. The common duct (CBD) was examined in 25 cases and the pancreatic duct (PD) in 1. In 13 cases (group 1) the SCPS was used to evaluate potentially malignant strictures. There were 4 cases (group 2) where the SCPS was used for EHL of large CBD stones. In 9 cases (group 3) the SCPS was used in the diagnostic evaluation of various findings in the CBD or PD. In group 1 the Spyscope catheter was successfully used in 9/13 cases and the fiber/sphincterotome was used in 5/13 cases to visualize cbd strictures. Tissue was obtained in all pts by standard forceps, brushing, or the miniature Spy forceps (5/13 cases) and was diagnostic of malignancy in 4/13 pts. Spy forceps provided sufficient tissue in 4/5 biopsies, with 2 demonstrating mailignancy. In group 2 stones were visualized well and good placement of the EHL probe occurred in all cases. Stone pulverization only occurred in 1/3 patients (1/4 cases). In group 3 the Spyscope catheter was used in 7/9 cases and the fiber/sphincterotome in 2/9 cases. Examination ruled out stone, mass or stricture in 7/9 cases. Directed wire guided cannulation of an intrahepatic duct was performed in one case. A choledochal cyst was successfully sampled with Spy forceps in one case. SPCS examiniation was found to be clinically useful in all pts in group 3. Conclusion: Our initial use of the SCPS proved successful in evaluating complex biliary and pancreatic issues. Excellent visualization was achieved in all cases. SPCS added to our ability to biopsy malignant strictures, though the yield was lower than expected in this early experience. EHL was technically facilitated though two cases of very hard stones proved recalcitrant. SPCS was found to be clinically useful in the majority of cases.

Sphinterotomy Plus Large Balloon Papillary Dilatation for Large Bile Duct Stones

Backgraound: One of the main problems in removing CBD stone is large stone size (>15 mm). It requires prolonged time and repeated procedure to remove large CBD stone. And there is higher risk of bleeding during wide EST. The aim of this study was to determine the utility of paillary dilatation with large balloon after EST. Method: Seventy patients with large (>15 mm) CBD stone were enrolled for this study. The patients underwent papillary dilatation with a 15 mm or 20 mm diameter balloon after EST (mid-incisoin). Then, stones were extracted by basket. And additional mechanical lithotripsy was done when stone removal was unsuccessful. Result: The maximum stone diameter was 21.5 mm. Average number of stones was 1.4. Periampullary diverticulum was found in 16 patient. Complete stone removal was achieved in all patient. We used 15 mm balloon in 25 patient, 20 mm balloon in 45 patient. And we needed mechanical lithotripsy in 11 patients in whom stone removal was unsuccessful by basket extraction. After the procedure, the serum amylase and/or lipase levels were elevated in 9 patients (12%). But, true pancreatitis was noted in only three patient (4%). Minor bleeding was encountered in 10 patients (14%) and was controlled spontaneously or by balloon compression. There was no critical complication such as perforation, severe pancreatitis, active bleeding or death. Conclusion: Large balloon papillary dilatation after EST is safe and effective method for treatment of large CBD stones. And this method can reduce the procedure time or repeated ERCP.

Minor EST with EPLBD Is a Safe Treatment Modality for Removal of Difficult Bile Duct Stones in Patients with Periampullary Diverticuli

Background/Aims: Periampullary diverticuli (PAD), which are frequently noticed during endoscopic retrograde cholangiopancreatography (ERCP) examination in patients with pancreaticobiliary diseases, have been reported to be associated with difficult bile duct canulation and an increased incidence of endoscopic sphincterotomy (EST). The aim of this study is to investigate the safety of combined minor EST and endoscopic papillary large balloon dilatation (EPLBD) for the removal of difficult CBD stones in patients with periampullary diverticuli group by comparing the success rate of stone removal and complications with patients who have normal ampullas. Patients and Methods: Between May 2005 and Sep. 2006, 69 patients underwent minor EST with EPLBD for the removal of CBD stones. Thirty two patients(mean age 71.8 years; 12 men, 20 women) had periampullary diverticului and thirty seven patients(mean age 66.9 years; 17 men, 20 women) had normal ampulla. Results: The mean number of CBD stones was 2.5 in PAD and 3.2 in normal. The mean diameter of stones was 17.5 mm and 18.2 mm, respectively. The success rate of complete stone removal for first endosocopic session was 93.8% (30/32) in the PAD group and 89.2% (33/37) in the normal ampullary group (p > 0.05). The complication rate was 3.1% (1/32; delayed bleeding) in the PAD group and 10.8% (4/37; all were mild pancreatitis) in the normal ampullary group (p > 0.05). The overall success rate of stone removal was 100% in both group. Conclusion: Minor EST with EPLBD in PAD is a safe treatment modality for removal of large CBD stones.

Mechanical Lithotripsy (ML) of Pancreatic Biliary Stones: Complications and Available Treatment Options Collected from Expert Centers

Large and/or impacted PD and CBD stones often require ML at ERCP for successful endoscopic extraction. Many have reported on the outcome of refractory pancreatic-biliary stones. Rate and spectrum of complications is not well described. Complications are varied and include failure of basket to open in confined space, trapped basket surrounding a stone, fracture of basket wires, malfunction of ML crank handle, and ductal injury. METHODS: 6 tertiary referral centers participated in this comprehensive review. All centers identified the total # of cases requiring ML of large or resistant PD and CBD stones. Centers reviewed each case for type(s) of complication, Rx attempted, and success of Rx. A 56 data point questionnaire was filled by all investigators for each complication. Completed forms were returned for data analysis at the host institution. RESULTS: 695 ML cases were identified. 628 were biliary (90.4%) while 67 were pancreatic (9.6%). Complications were distributed at follows: 21 of 628 biliary (3.3%) and 7 of 67 pancreatic (10.5%). Of the 28 complications, 19 were single complications, 9 cases were multiple. Complications in the biliary group included: trapped (TR)/broken (BR) basket (n=10), wire fracture (FX) (n=8), failure to open (n=4), broken (BR) handle (n=4), perforation/duct injury (n=3). Complications in the pancreatic group included: TR/BR basket (n=6), wire FX (n=3), failure to open (n=1), BR handle (n=3). Rx of complications in the biliary group included: sphincterotomy (ES) extension (n=7), electrohydraulic lithotripsy (EHL) (n=11), stent (n=3), per-oral Soehendra lithotripsy (n=8), surgery (n=1). Rx of complications in the pancreatic group included: ES extension (n=2), EHL (n=2), stent (n=3), Soehendra (n=4), extracorporeal lithotripsy (ECL) (n=1), surgery (n=1). Pt with perforated viscus died at 30d. CONCLUSIONS: The vast majority of ML in expert centers involve the bile duct. The complication rate of pancreatic ML is 3 fold greater than biliary ML. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most useful treatment options.