Mechanical Lithotripsy Research Articles

Partial papillosphincterotomy with balloon dilatation in the treatment of choledocholytiasis in patients with parapapillary diverticulum

Results of treatment of 42 patients suffering from choledocholytiasis and parapapillary diverticle are compared, by which for treatment limited papillosfincterotomy supplemented with endoscopic balloon dilatation is performed with results of treatment of 56 patients with similar pathology, by which traditional endoscopic papillosfincterotomy was performed. Limited papillosphincterotomy with endoscopic balloon dilatation resulted in complete lithoextraction in 92.9% of cases as compared to 92.8% with endoscopic papillosphincterotomy only; an adequate drainage of extrahepatic bile ducts was achieved in 100% and 96.4%, respectively (p 0.05). With endoscopic papillosphincterotomy, full removal of all concretions with a diameter of less than one centimeter was achieved without mechanical lithotripsy; for concretions from 1 to 1.5 cm in size the mechanical lithotripsy was necessary in 45.5% of cases. Limited papillosphincterotomy with endoscopic balloon dilatation allowed lithoextraction of concretions with a diameter of up to 1.5 cm without mechanical lithotripsy in all patients. The mechanical lithotripsy for concretions with a diameter above 1.5 cm was necessary in 60% of cases for both methods. In the treatment arm, two (4.8%) cases with complications were observed, while in the control arm there were 13 (23.2%) cases (p = 0.012). Acute pancreatitis was the only postoperative complication for which significant difference was observed (р = 0.043). In addition, after endoscopic papillosphincterotomy the incidence of bleeding from the suture line was 3.6% and the incidence of perforation of diverticula was 3.6%; this required an open surgery. The above mentioned demonstrates the advantages of limited papillosphincterotomy with endoscopic balloon dilatation over endoscopic papillosphincterotomy to resolve choledocholytiasis in the presence of parapapillary diverticulum.

Predictors of recurrent bile duct stone after clearance by endoscopic retrograde cholangiopancreatography: A case-control study

BackgroundRecurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone. MethodsWe performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone. ResultsIn univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69–55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05–318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00–1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19–0.81, P = 0.012) was a protective factor. ConclusionsWe identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk.

Жовчнокам’яна хвороба, ускладнена холедохолітіазом: сучасні аспекти діагностики

Choledocholithiasis is an urgent problem of modern hepatobiliary surgery and accounts for 60% of all obstructive jaundice. Stones of the common bile duct cause cholestasis and mechanical jaundice syndrome and in case of untimely diagnostics lead to the development of such severe complications as acute cholangitis and biliary sepsis. The criteria for determining the sequence, stages and volume of diagnostic measures with choledocholithiasis have not been determined by now. The purpose of the study. Optimization of the instrumental stage of the diagnostics of patients with choledocholithiasis. Materials and methods. 56 patients with choledocholithiasis were studied. The diagnostic program was expanded due to the instrumental stage using ultrasound, duodenopapiloscopy, endoscopic retrograde cholangiopancreatography and magnetic resonance tomography. The criterion for the patients selection was the syndrome of distal choledochal patency violation and the presence of stones in it according to echosonography and endoscopic cholangiopancreatography. Results and discussion. At sonography bilious hypertension was established in all 72 (100%) patients. Mechanical jaundice was present in 54 (96.4%) patients. Hepatic dysfunction with 84±9.6 mmol/l hyperbilirubinemia and an increase in AST and ALT levels to 1.2±0.9 mmol/l and 1.5±1.1 mmol/l, were verified respectively. At endoscopic retrograde cholangiopancreatography choledocholithiasis was found in 54 (96.4%) patients. Single stones were present in 18 (32.1%) and multiple – in 38 (67.9%) patients. In 52 (92.9%) cases, stones up to 1.5 cm in diameter were removed with a Dormia basket at one time or after mechanical lithotripsy. In 4 (7.1%) patients stones from 1.7 to 2.0 cm could not be removed endoscopically. Choledoch stenting was performed in 12 (21.4%) patients. One-stage transpapillary treatment was carried out in 38 (67.9%) patients, two and three stage treatment – in 14 (25%) cases, and «open» choledocholithotomy – in 4 (7.1%) cases. Conclusion. The program of choledocholithiasis diagnostics with the gradual use of clinical, laboratory, radiological and endoscopic data allows carrying out correct detailing of the cause, level, degree of common bile duct obstruction and the complicated course of the disease in 100% of cases

Direct cholangioscopy using a standard-size gastroscope to guide mechanical lithotripsy after failed ERCP-based basket capture

Direct cholangioscopy using a standard-size gastroscope to guide mechanical lithotripsy after failed ERCP-based basket capture

The ballooning time in endoscopic papillary balloon dilation for removal of bile duct stones: A systematic review and meta-analysis.

Background:So far, there was no consensus regarding balloon dilation time in endoscopic papillary balloon dilation (EPBD). Thus, we conducted a systematic review and meta-analysis to compare the stone removal and overall complication rates of dilation of short and long duration with EPBD.Methods:The Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library), Web of Science, EMBASE Databases, and PubMed were searched from their inception to December 1, 2019 for all articles regarding balloon dilation time in EPBD for removal of bile duct stones. The data were extracted and the methodology quality was assessed. Meta-analysis was performed using RevMan5.3 software.Results:Four studies involving a total of 1553 patients were included, 918 in the short dilation group and 635 in the long dilation group. The results of meta-analysis showed that there was no significant difference between the 2 different dilation groups in the complete stone removal in randomized controlled trails (RCTs) group (P = .10) and non-RCTs group (P = 0.45), mechanical lithotripsy requirement (RCTs: P = .92; non-RCTs: P = .47), pancreatitis (RCTs: P = .48; non-RCTs: P = .45), bleeding (RCTs: P = .95; non-RCTs: P = .60), infection of biliary (RCTs: P = .58; non-RCTs: P = .29), perforation (RCTs: P = .32; non-RCTs: P = .37).Conclusion:This systematic review suggests that there no significant difference in the efficacy and safety of dilation of short and long duration for removal of bile duct stones with EPBD.

Cracking Difficult Biliary Stones.

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.

Immediate or Interval Endoscopic Papillary Large-balloon Dilation after Limited Endoscopic Sphincterotomy for Bile Duct Stone Removal.

Objective Endoscopic papillary large-balloon dilation (EPLBD) with limited endoscopic sphincterotomy (EST) is widely used for removing multiple large common bile duct (CBD) stones. However, the safety and effectiveness of immediate EPLBD after limited EST and EPLBD at an interval after limited EST is unclear. Thus, this multicenter retrospective study was conducted to examine this matter. Methods Propensity score-matching was performed to adjust the baseline characteristics between the immediate and interval EPLBD groups. We compared the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) complications and the early outcomes of ERCP between the 2 matched groups, which comprised 66 patients each. Results The complete stone clearance rate in each study group was 100%. The overall incidence of post-ERCP complications in the propensity score-matched interval and immediate EPLBD groups was 3/33 (9.1%) and 1/33 (3.0%), respectively (p=0.61). The immediate EPLBD group had significantly fewer mean ERCP sessions for complete stone removal and a significantly lower rate of endoscopic mechanical lithotripsy (EML) usage than the interval EPLBD group [1.6 vs. 2.4 sessions, p<0.001; and 4/33 (12.1%) vs. 12/33 (36.4%), p=0.042, respectively]. Conclusion The incidence of post-ERCP complications in the immediate EPLBD group was not significantly different from that in the interval EPLBD group. Compared with interval EPLBD, immediate EPLBD may result in a reduced number of ERCP sessions for complete stone clearance and reduce the rate of EML usage.

Endoscopic retrieval of a proximally migrated biliary stent using extracorporeal shockwave lithotripsy, electrohydraulic lithotripsy, and cholangioscopy with minisnare.

Video 1ERCP was notable for a proximally migrated biliary stent. Cholangiogram demonstrated multiple filling defects consistent with choledocholithiasis surrounding the proximally migrated biliary stent. Retrieval of the stent was successful using cholangioscopy-directed electrohydraulic lithotripsy, extracorporeal shockwave lithotripsy, mechanical lithotripsy, and minisnare over the course of 2 ERCPs. Complete duct clearance of stones was accomplished with balloon sweeps.

Emergency open surgery with a duodenotomy and successful removal of an impacted basket following a complicated endoscopic retrograde cholangiopancreatography procedure: a case report

BackgroundCurrent management of choledocholithiasis entails the use of endoscopic retrograde cholangiopancreatography (ERCP) and clearance of the common bile duct. A rare complication of this procedure is the impaction of the basket by a large stone, which necessitates lithotripsy. Here we report a case of an impacted basket during ERCP, which was managed by open surgery with a duodenotomy and the manual removal of the basket.Case presentationA 79-year-old Caucasian man was admitted to our department with yellowish discoloration of urine, skin and eyes. Abdominal ultrasonography showed a slightly thickened gallbladder, multiple gallbladder stones, dilated intrahepatic bile ducts and extrahepatic bile extending to 1.1 cm. A computed tomography (CT) scan demonstrated a stone in the common bile duct, which caused dilation of the biliary ducts. The patient was diagnosed with obstructive jaundice secondary to choledocholithiasis; and underwent an ERCP, a sphincterotomy and stone extraction. Four days following discharge, the patient was readmitted with jaundice, abdominal pain, vomiting and fever. He was diagnosed with ascending cholangitis and treated initially with antibiotics. A second ERCP revealed a dilated common bile duct and choledocholithiasis. Stone removal with a basket failed, as did mechanical lithotripsy. Finally, the wires of the basket were ruptured and stacked in the common bile duct together with the stone. During exploratory laparotomy, adhesiolysis, a Kocher maneuver of the duodenum and a subtotal cholecystectomy were performed. Choledochotomy did not succeed in removing the impacted wires together with the stone. Therefore, a duodenotomy and an extension of the sphincterotomy were performed, followed by high-pressure lavage of the common bile duct to remove additional small biliary stones. The choledochotomy and duodenotomy were closed by a one-layer suture, and a prophylactic gastroenterostomy was performed to prevent leakage from the common bile duct and the duodenum. The postoperative course was satisfactory.ConclusionsThis is the first report in the literature of removal of an impacted Dormia basket through the papilla by performing a duodenotomy and an extension of the sphincterotomy, followed by gastroenterostomy.

Dilation assisted stone extraction for complex biliary lithiasis: Technical aspects and practical principles

Common bile duct stones are frequently diagnosed worldwide and are one of the main indications for endoscopic retrograde cholangio-pancreatography. Endoscopic sphincterotomy (EST) has been used for the removal of bile duct stones for the past 40 years, providing a wide opening to allow extraction. Up to 15% of patients present with complicated choledocholithiasis. In this context, additional therapeutic approaches have been proposed such as endoscopic mechanical lithotripsy, intraductal or extracorporeal lithotripsy, or endoscopic papillary large balloon dilation (EPLBD). EPLBD combined with EST was introduced in 2003 to facilitate the passage of large or multiple bile duct stones using a balloon greater than 12 mm in diameter. EPLBD without EST was introduced as a simplified technique in 2009. Dilation-assisted stone extraction (DASE) is the combination of two techniques: EPLBD and sub-maximal EST. Several studies have reported this technique as safe and effective in patients with large bile duct stones, without any increased risk of adverse events such as pancreatitis, bleeding, or perforation. Nevertheless, it is difficult to analyze the outcomes of DASE because there are no standard techniques and definitions between studies. The purpose of this paper is to provide technical guidance and specific information about the main issues regarding DASE, based on current literature and daily clinical experience in biliary referral centers.

A heart-shaped calculus in the bile duct: a difficult stone extraction requiring papillary dilation and mechanical lithotripsy

A heart-shaped calculus in the bile duct: a difficult stone extraction requiring papillary dilation and mechanical lithotripsy

Could saline irrigation clear all residual common bile duct stones after lithotripsy? A self-controlled prospective cohort study

BACKGROUNDA previous study showed that irrigation with 100 mL saline reduced residual common bile duct (CBD) stones, which potentially cause recurrent stones after endoscopic retrograde cholangiopancreatography.AIMTo determine whether saline irrigation can improve CBD clearance after lithotripsy.METHODSThis prospective self-controlled study enrolled patients receiving mechanical lithotripsy for large (> 1.2 cm) CBD stones. After occlusion cholangiography confirmed CBD stone clearance, peroral cholangioscopy (POC) was performed to determine clearance scores based on the number of residual stones. The amounts of residual stones spotted via POC were graded on a 5-point scale (score 1, worst; score 5, best). Scores were documented after only stone removal (control) and after irrigation with 50 mL and 100 mL saline, respectively. The stone composition was analyzed using infrared spectroscopy.RESULTSBetween October 2018 and January 2020, 47 patients had CBD clearance scores of 2.4 ± 1.1 without saline irrigation, 3.5 ± 0.7 with 50 mL irrigation, and 4.6 ± 0.6 with 100 mL irrigation (P < 0.001). Multivariate analysis showed that CBD diameter > 15 mm [odds ratio (OR) = 0.08, 95% confidence interval (CI): 0.01-0.49; P = 0.007] and periampullary diverticula (PAD) (OR = 6.51, 95%CI: 1.08-39.21; P = 0.041) were independent risk factors for residual stones. Bilirubin pigment stones constituted the main residual stones found in patients with PAD (P = 0.004).CONCLUSIONIrrigation with 100 mL of saline may not clear all residual CBD stones after lithotripsy, especially in patients with PAD and/or a dilated (> 15 mm) CBD. Pigment residual stones are soft and commonly found in patients with PAD. Additional saline irrigation may be required to remove retained stones.

Key Features for Prediction of Post-ERCP-Cholecystitis (PEC):&amp;nbsp;A Novel Machine Learning Model and a Public Online Prediction Platform

Background: Post-endoscopic retrograde cholangiopancreatography (ERCP) cholecystitis (PEC) is an ignored but serious complication. Methods: A random forest (RF) machine learning method was used to develop a predictive model for PEC. Eligible patients with common bile duct (CBD) stones and gallbladders in-situ were retrospectively enrolled to build the model. Logistic regression analysis was used to compare the predictive value based on sensitivity, specificity, accuracy, and area under the curve (AUC). The predictive value of the RF model was further validated with another 117 patients. This study was registered with ClinicalTrials.gov, NCT04234126 is completed. Findings: A total of 1,117 patients were enrolled (90 PEC, 8.06%) to build the predictive model for PEC. The RF method identified white blood cell (WBC) count, endoscopic papillary balloon dilatation (EPBD), increase in WBC, residual CBD stones after ERCP, serum amylase levels, and mechanical lithotripsy were the top six predictive factors and has a sensitivity (0.822), specificity (0.853), accuracy (0.855), and AUC values (0.890). A separate logistic regression prediction model was built showing a sensitivity, specificity, and AUC of 0.800, 0.801, and 0.864, respectively. An additional 117 patients (11 PEC, 9.40%) were used to validate the RF model, with an AUC of 0.889 compared to an AUC of 0.884 with the logistic regression model (95% CI, 0.783 - 0.986). The web server is available online at http://101.35.163.113/PEC/. Conclusions: The RF model both validated by logistic regression based on the top six risk factors as listed above accurately predicted the occurrence of PEC. Clinical Trial Registration Details: Registered with Clinicaltrial.gov (NCT04234126). Funding Information: This work was supported by National Natural Science Foundation of China (8187103130; 32160255); Gansu Competitive Foundation Projects for Technology Development and Innovation (1602FKDA001); Gansu Province Science and Technology Planning Project (20YF8WA085); Science and Technology Planning Project of Chengguan District in Lanzhou (2020JSCX0043). The Foundation of The First Hospital of Lanzhou University (ldyyyn-2018-16). Declaration of Interests: No conflict of interest was declared by the authors. Ethics Approval Statement: This retrospective study was conducted in the surgical endoscopy center of The First Hospital of Lanzhou University in China, in accordance with the Declaration of Helsinki. The study was approved by the Ethics Committee of The First Hospital of Lanzhou University (LDYYLL2021-257).

Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy.

The most effective and the standard treatment for bile duct stones (BDSs) is endoscopic retrograde cholangiopancreatography (ERCP). However, in 10% to 15% of patients with BDSs, the stones cannot be removed by conventional ERCP, which involves endoscopic sphincterotomy followed by balloon or basket extraction. Additional techniques or devices are often necessary to remove these difficult bile-duct stones, including endoscopic papillary large balloon dilatation to make a larger papillary opening and/or mechanical lithotripsy to fragment the stones. Advances in cholangioscopy have made possible electrohydraulic or laser lithotripsy under direct cholangioscopic visualization during ERCP. Cholangioscopy-guided lithotripsy could be another good option in the armamentarium of techniques for removing difficult BDSs. Here we review endoscopic techniques based on single-operator cholangioscopy for the management of difficult BDSs.

Best Procedure for the Management of Common Bile Duct Stones via the Papilla: Literature Review and Analysis of Procedural Efficacy and Safety.

Background: Endoscopic management of common bile duct stones (CBDS) is standard; however, various techniques are performed via the papilla, and the best procedure in terms of both efficacy and safety has not been determined. Methods: Endoscopic procedures were classified into five categories according to endoscopic sphincterotomy (EST) and balloon dilation (BD): (1) EST, (2) endoscopic papillary BD (≤10 mm) (EPBD), (3) EST followed by BD (≤10 mm) (ESBD), (4) endoscopic papillary large BD (≥12 mm) (EPLBD), and (5) EST followed by large BD (≥12 mm) (ESLBD). We performed a literature review of prospective and retrospective studies to compare efficacy and adverse events (AEs). Each procedure was associated with different efficacy and AE profiles. Results: In total, 19 prospective and seven retrospective studies with a total of 3930 patients were included in this study. For EST, the complete stone removal rate at the first session, rate of mechanical lithotripsy (ML), and rate of overall AEs in EST were superior to EPBD, but a higher rate of bleeding was found for EST. Based on one retrospective study, complete stone removal rate at the first session, rate of ML, and rate of overall AEs were superior for ESBD vs. EST, and the rate of bleeding for the former was also lower. Complete stone removal rate at the first session and rate of ML for ESLBD were superior to those for EST, with no significant difference in rate of AEs. For EST vs. EPLBD, complete stone removal rate at the first session and rate of ML were superior for the latter. For EPLBD vs. ESLBD, the efficacy and safety were similar. Conclusions: ESBD is considered the best procedure for the management of small CBDS, but strong evidence is lacking. For large CBDS, both ESLBD and EPLBD are similar.

Novel peroral cholangioscopy-directed lithotripsy using an ultraslim upper endoscope for refractory Mirizzi syndrome

Rationale:Mirizzi syndrome (MS) is an uncommon condition characterized by common hepatic duct (CHD) compression by an impacted gallbladder or cystic duct stones or adjacent inflammation. To date, a standardized therapeutic strategy for MS has not been established yet, owing to its complex clinical presentation. Thus, researchers still have to develop new optimized approaches to solve this problem. Herein, we describe a patient with refractory MS who underwent a successful treatment by novel hybrid anchoring balloon-guided direct peroral cholangioscopy (POC) using an ultraslim endoscope.Patient concerns:A 56-year-old man with a history of biliary stone was referred to our hospital for complaints of discomfort in the right upper quadrant of the abdomen and obstructive jaundice. Endoscopic retrograde cholangiopancreatography showed an 18-mm impacted stone at the level of the cystic duct, which compressed the CHD. The CHD had local stricture, with its upstream and intrahepatic bile duct dilation.Diagnoses:He was diagnosed with type I MS.Interventions:Initially, the patient received an endoscopic major sphincterotomy. However, conventional stone extraction, including mechanical lithotripsy, was unsuccessful. Then, after signing the informed consent form for further treatment, he was successfully treated with novel hybrid anchoring balloon-guided direct POC.Outcomes:The patient had no operative complications and was discharged with cleared ducts. At the 3-year follow-up, he was asymptomatic.Lessons:Our novel hybrid anchoring balloon-guided direct POC may be an effective alternative treatment approach for difficult gallbladder cases, such as refractory MS.

Predictors of failure of endoscopic retrograde pancreatocholangiography during common bile duct stones

IntroductionEndoscopic retrograde cholangiopancreatography associated with sphincterotomy and stone extraction with balloon or Dormia basket represents the gold standard for the management of common bile duct stones. The aim of our study were to investigate the predictors of failure of standard endoscopic techniques during the management of common bile duct stones. MethodsA retrospective study including all endoscopic retrograde cholangiopancreatography for common bile duct stones between January 2014 and December 2017 was conducted. First line treatment was based on endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and balloon or Dormia extraction. Second line endoscopic treatment was based on macrodilatation of Oddi sphincter, mechanical lithotripsy, biliary stent or nasobiliary drain placement. Predictors of failure of standard endoscopic techniques were sought by uni and multivariate analysis (SPSS software, p significant if < 0.05). ResultsOne hundred eighty one patients (mean age 64 years and sex ratio M/W = 0.4) were included. Main indications for endoscopic retrograde cholangiopancreatography were residual or recurrent lithiasis (67.4%, n = 122). Cholangiography revealed multiple stones in 53 patients with an average size of 12.5mm [3–40]. The success rate of first line treatment was 61.9%. Independent predictors of failure of standard endoscopic techniques (failure of papillary cannulation or stone extraction) according to multivariate analysis were: an age greater than 65 years OR 0.516 [0.272–0.979], an intra-diverticular papilla OR 0.179 [0.035–0.914], a common bile duct diameter greater than 15 mm OR 0.161 [0.068–0.385] and a stenosis of the common bile duct OR 0.068 [0.008–0.605]. The success rate of the second line treatment was 73%. ConclusionEndoscopic retrograde cholangiopancreatography results in a successful clearance of the common bile duct in almost two-thirds of patients. In case of predictors of failure, alternative techniques can increase this rate.

S1560 Bouveret’s Syndrome; A Rare Cause of Gastric Outlet Obstruction

INTRODUCTION: Bouveret’s syndrome is an extremely rare cause of gastric outlet obstruction secondary to gallstone impaction in the duodenum or stomach via bilioenteric fistula. This syndrome is most commonly seen in elderly woman with multiple comorbidities and has been associated with mortality rates between 12-30%. CASE DESCRIPTION/METHODS: An 80-year-old female with a past medical history significant for diabetes, hypertension, and hyperlipidemia presented with two days of postprandial nausea and vomiting. Patient had no complaint of recent abdominal pain. CT of the abdomen and pelvis with oral contrast demonstrated a 2.2 cm mass with rim calcification considered to be the cause of gastric outlet obstruction (pneumobilia was not reported but present) [Image 1]. An EGD was performed and the endoscope was advanced through a widely patent pylorus. A 4 cm gallstone was noted just proximal to the duodenal sweep [Image 2]. A Roth net was able to partially grasp the gallstone but was unable to remove it through the pylorus [Image 3]. A lithotripsy biliary basket was not able to retrieve the stone across of the pylorus due to stone size, and mechanical lithotripsy was unsuccessful. An electrohydraulic lithotripsy probe was used for lithotripsy but was ineffective at completely removing the stone. The patient was then referred to surgery, and on the following day she underwent laparoscopic gastrotomy but the gallstone could not be located. An exploratory laparotomy was performed and the gallstone was discovered in the distal ileum, requiring an enterotomy for removal. There were no complications post-operatively and the patient recovered. DISCUSSION: Bouveret’s syndrome is the rarest form of gallstone ileus occurring in only 1-3% of cases. Often patients present with vague abdominal symptoms which can delay diagnosis and appropriate treatment. Although present on 73% of CT images, Rigler’s triad (small bowel obstruction, pneumobilia, and ectopic gallstone), which is specific to Bouveret’s syndrome, is only recognized preoperatively in 60% of cases. Endoscopic management should be considered as the first line management option, due to the minimally invasive approach. Unfortunately, as demonstrated in this case, endoscopic management is not successful in 30-40% of cases, and surgery is necessary. Our case also demonstrates the risk of endoscopic intervention as the stone was found lodged at the ileocecal valve likely precipitated by stone manipulation emphasizing need for coordination with surgery.Figure 1.: Image 1 – CT of the abdomen and pelvis demonstrating Rigler’s triad: 2.2 cm in size rim calcified mass (blue arrow), gastric distention consistent with obstruction (orange arrow), and an abnormally thickened gallbladder (yellow arrow) with pneumobilia (green arrow).Figure 2.: Image 2 – Endoscopic view of gallstone obstructing duodenum just proximal to the duodenal sweep.Figure 3.: Image 3 – Endoscopic view of the gallstone as an attempt is made to pull gallstone through pylorus via Roth net.

S2772 Bouveret Syndrome: Using Electrohydraulic Lithotripsy to Clear the Way

INTRODUCTION: Bouveret syndrome is a rare form of gallstone ileus that occurs by passage of a gallstone through an acquired cholecystoduodenal or cholecystogastric fistula into the enteric lumen leading to gastric outlet obstruction. It is seen in less than 0.5% of patients with cholelithiasis and represents 1-3% of all gallstone ileus cases. Although several cases of Bouveret Syndrome exist within the literature, we describe a rare case using electrohydraulic lithotripsy (EHL) as a successful treatment option. CASE DESCRIPTION/METHODS: A 67-year-old man with past medical history significant for metastatic melanoma and history of locally advanced tonsillar carcinoma presented to the hospital with acute onset nausea, vomiting, and abdominal pain for 2-day duration. On physical exam, he was afebrile and hemodynamically stable. His abdomen was mildly distended and tender without guarding. Lab assessment was unremarkable. An abdominal computed tomography (CT) revealed a cholecystoduodenal fistula and an obstructing calcified stone in the duodenum with pneumobilia (Figure 1). After a discussion with surgery, the patient was taken for an esophagogastroduodenoscopy (EGD) revealing a large, approximately 3 cm stone completely occluding the duodenal sweep (Figure 2). EHL under water immersion was used to break up the impacted stone. Small pieces were continuously removed from the duodenal lumen with a tripod grasper and placed in the stomach where they were further fragmented. Following gallstone clearance, a large ulcer and cholecystoduodenal fistulous tract was present in the duodenal sweep (Figure 3). The patient did well after the procedure and discharged home without complications. DISCUSSION: Being that Bouveret syndrome is rare and symptoms are nonspecific, a high clinical suspicion needs to exist to make an accurate diagnosis. Imaging findings suggestive of Bouveret syndrome include a dilated stomach, pneumobilia, and a radio-opaque shadow suggesting a gallstone. These findings make up Rigler's triad. Treatment options include surgery and endoscopic interventions. Multiple endoscopic modalities are utilized for the treatment of this syndrome including removal baskets, mechanical lithotripsy, electrohydraulic lithotripsy, and laser lithotripsy. EHL is commonly used, but only successful in 10 % of cases. Although reports of endoscopic success are poor in the literature it should be attempted to decrease the morbidity and mortality associated with surgery that can be as high as 25%.Figure 1Figure 2Figure 3

Tratamiento de la coledocolitiasis mediante CPRE e instrumentación a través de un tubo en T

El tratamiento de la coledocolitiasis ha evolucionado de forma significativa desde que Robert Abbe realizó la primera coledocotomía y la exploración de las vías biliares en Nueva York, en 1889. La colangiopancreatografía retrógrada endoscópica (CPRE), que inicialmente fue un método diagnóstico, ahora solo tiene validez como método terapéutico. En la actualidad, los principales métodos diagnósticos son la colangioresonancia magnética (CRM) y la ultrasonografía endoscópica (USE). El tratamiento de la coledocolitiasis pasó de la técnica quirúrgica abierta -en la que, de forma rutinaria, se realizaba la coledocorrafia sobre un tubo de Kehr o tubo en T- a la endoscópica, mediante el uso de la CPRE, la esfinteroplastia y la instrumentación con balones y canastilla. Hoy en día se dispone de técnicas adicionales como la litotricia mecánica (LM) o extracorpórea, la dilatación con balón (DB) de gran tamaño y el Spyglass®. La técnica laparoscópica se usa desde hace varios años, en diversas partes del mundo, para el tratamiento de la coledocolitiasis. Estudios recientes proponen incluso el cierre primario del colédoco o la coledocoduodenostomía, con lo cual no sería necesaria la utilización del tubo en T. Pero en muchos otros sitios, y por diversas razones, se continúa usando la exploración quirúrgica abierta y el tubo en T, que representa una importante opción en el tratamiento de algunos pacientes.&#x0D; Caso clínico: paciente masculino de 88 años, con coledocolitiasis recidivante, cálculo gigante de difícil manejo endoscópico y sepsis de origen biliar, que requirió drenaje quirúrgico abierto de urgencias. Se realizó una coledocotomía, y se dejó el tubo en T. Posteriormente, se efectuó un tratamiento exitoso conjunto, mediante instrumentación por el tubo en T, por parte de cirugía general, y CPRE, por gastroenterología.