Biliary Stone Removal Research Articles

Removal of obstructed pancreatic stent tube and biliary stones in patient with Roux-en-Y anatomy under direct endoscopic view.

Removal of obstructed pancreatic stent tube and biliary stones in patient with Roux-en-Y anatomy under direct endoscopic view.

Cholangioscopic removal of complicated biliary stones aided by a metal stent extending from gallbladder to duodenal papilla (with video)

Cholangioscopic removal of complicated biliary stones aided by a metal stent extending from gallbladder to duodenal papilla (with video)

Safety, efficacy, and feasibility of percutaneous transhepatic endoscopic holmium laser lithotripsy for bile duct stones.

To evaluate the safety and efficacy of percutaneous transhepatic endoscopic holmium laser lithotripsy (PTEHL) for patients with intrahepatic bile duct (IHBD) and common bile duct (CBD) stones. This retrospective study included 530 patients (mean age: 55.6 ± 8.5; 64.2% female) with IHBD and/or CBD stones at a single institution from January 2019 to December 2021. PTEHL was the chosen treatment for patients with large, complex stones, or those for whom Endoscopic Retrograde Cholangiopancreatography (ERCP) failed or presented difficulties. Patients showing signs of cholangitis required pre-PTEHL drainage. Stone clearance was confirmed by post-procedural cholangiography, and the technique was deemed successful when target stones were removed. Complications were recorded according to the Society of Interventional Radiology adverse event classification. The mean stone size was 20.9 ± 11.9 mm, multiple stones observed in 460 patients (86.8%). A total of 225 patients (42.5%) had stones in both the IHBD and CBD; biliary-enteric anastomosis in 50 patients (9.4%). ERCP for stone removal proved unsuccessful in 18 patients (3.4%). Pre-IHBD drainage was performed in 271 patients (51.1%). The majority (488 patients, 92.1%) underwent a single PTEHL session. The technique was successful in 523 patients (98.7%), with 7 patients requiring surgery due to unsuccessful target stone removal. Complications were noted in 75 patients (14.2%), including 4.7% with severe complications and 9.4% with minor complications. PTEHL is a safe and effective method for the treatment of both intrahepatic and extrahepatic bile duct stones. This approach is a valuable option for complex stone cases, particularly when ERCP is unsuccessful or encounters significant challenges. Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy is a safe and effective treatment method for intrahepatic and extrahepatic biliary stones, particularly in cases of complex stones. Percutaneous transhepatic biliary stone removal is difficult for large or intraductal stones. Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy (PTEHL) demonstrated a high success rate with few major complications. PTEHL can treat biliary stones, particularly stones that are difficult or have failed ERCP treatment.

Endoscopic Retrograde Cholangiopancreatography (ERCP) for Suspected Mirizzi Syndrome Type IV as Both a Diagnostic and Bridge-to-Surgery Procedure.

Mirizzi syndrome (MS) is a challenging diagnosis due to its similar presentation with other biliary diseases; thus, the role of endoscopy is sometimes unclear, especially in altered anatomy. Radiological examinations may usually suspect it, but deeper examinations could be necessary to confirm it. Endoscopic retrograde cholangiopancreatography (ERCP) certainly has a therapeutic role in cases of jaundice, cholangitis or concurrent choledocolithiasis, although surgery is without doubt the definitive treatment in most of the cases. Therefore, surgeons may have a clearer picture of the condition of the biliary tree with respect to fistulas thanks to ERCP, particularly in patients with a higher grade of MS (type higher than 2 in the Csendes classification). Therefore, a complete removal of biliary stones is sometimes not possible due to size and location, so biliary stenting becomes the only option, even if transitory. Our brief report is a further demonstration of the fundamental role of ERCP in managing MS, even when it has no long-term therapeutic aim but is performed as bridge-to-surgery, especially in cases with a more difficult biliary anatomy due to the type of fistula. Moreover, we truly suggest discussing patients affected with MS in a multidisciplinary board, preferably in tertiary hepatobiliary centers.

Endoscopic Management of Difficult Biliary Stones: An Evergreen Issue.

Choledocholithiasis is one of the most common indications for endoscopic retrograde cholangiopancreatography (ERCP) in daily practice. Although the majority of stones are small and can be easily removed in a single endoscopy session, approximately 10-15% of patients have complex biliary stones, requiring additional procedures for an optimum clinical outcome. A plethora of endoscopic methods is available for the removal of difficult biliary stones, including papillary large balloon dilation, mechanical lithotripsy, and electrohydraulic and laser lithotripsy. In-depth knowledge of these techniques and the emerging literature on them is required to yield the most optimal therapeutic effects. This narrative review aims to describe the definition of difficult bile duct stones based on certain characteristics and streamline their endoscopic retrieval using various modalities to achieve higher clearance rates.

Percutaneous approach for biliary stone removal

Percutaneous approach for biliary stone removal

Endoscopic Retrograde Cholangiopancreatography during Pregnancy

Physiological changes caused by pregnancy promote the formation of gallstones, increasing the risk of acute cholecystitis, cholangitis, and cholelithiasis that occur during pregnancy. Since these diseases can be fatal to both mother and fetus, active treatment is critical. Biliary gallstones are preferably treated using endoscopic retrograde cholangiopancreatography (ERCP), even during pregnancy. While there is no alternative, safer and easier treatment method, complications from ERCP are lethal; therefore, several risks and benefits must be considered. First, various tests should be conducted and considered to determine whether ERCP is necessary. The risk of congenital disabilities from radiation exposure to the fetus during ERCP should be considered and minimized. Furthermore, clinicians should be aware of and use safe anesthetic agents and antibiotics that are safe to use during pregnancy. Finally, ERCPists should be familiar with various technical methods, such as the recently introduced ERCP technique without radiation exposure, stent drainage without complete removal of gallstones in the case of large biliary stones, and removal of biliary stones after childbirth. Pregnancy is not a contraindication for ERCP; as a lifesaving procedure, it should be performed when necessary. Even though the safety of ERCP is considered an acceptable risk in pregnancy, clinicians should continue to try and find safer ways for pregnant women and fetuses being treated for cholelithiasis.

Commentary: Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal.

Commentary: Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal.

Percutaneous transhepatic biliary stone removal: A single-center retrospective study

Objectives: To report, the authors’ experience with percutaneous transhepatic biliary stone removal, focusing on the technical aspects and overall performance, as well as reviewing few challenging cases. Material and Methods: All cases of percutaneous transhepatic biliary stone removal from 2015 to 2022 were retrieved, including intrahepatic locations. Cases with negative initial cholangiogram suggestive of stone passage were excluded from the study. The demographic data, procedural indications and details, stone characteristics, fluoroscopic images, success rate, and complications were retrospectively evaluated by two experienced observers. Results: The final study included 67 patients (mean age = 76.8). Majority of indications were altered gastric anatomy and failed endoscopic retrograde cholangiopancreatography. The mean largest stone size was 9 mm and most cases had multiple stones. Balloon sphincteroplasty was performed in all cases and mechanical lithotripsy in 24%. Fourteen cases required repeated trials, and they were mostly staged, depending on technical factors and patient condition. Recurrent pyogenic cholangitis (RPC) usually required repeated trials, and two separate sites of catheterization were made in the same lobe for one challenging case. Complete stone retrieval was not achieved in 9% (six out of 67) of cases: failure of mechanical lithotripsy (n = 2); failure of balloon occlusion technique (n = 1); refluxed stone (n = 1); and multiplicity of intrahepatic stones (n = 2). Three minor complications were encountered, including sepsis and self-controlled hemobilia. No major complications. Conclusion: Percutaneous extrahepatic biliary stone removal is a safe and technically feasible procedure after a failed endoscopic approach or altered biliary tract anatomy. Cases of RPC or previous Whipple’s operation could be technically challenging. Careful pre-procedural planning and anatomical review are crucial.

Risk factors for complications in elderly patients aged 85 years and over undergoing endoscopic biliary stone removal.

Background and aimThe number of elderly patients with biliary stones is increasing. Endoscopic retrograde cholangiography (ERCP) is considered to be an effective treatment for biliary stones. Having a sound knowledge of the risk factors can help reduce the incidence and severity of complications for ERCP. Furthermore, limited research has been published on patients aged over 85 years undergoing endoscopic biliary stone removal. This study aims to determine the risk factors that lead to complications of ERCP in patients over 85 years of age.MethodsThis was a single-center retrospective study. We analyzed 156 patients aged ≥ 85 years with biliary stones who underwent their first ERCP at Chinese PLA General Hospital from February 2002 to March 2021. Logistic regression models were employed to identify the independent risk factors for complications.ResultsA total of 13 patients (8.3%) had complications. Thereinto, pancreatitis, cholangitis, bleeding, and other complications occurred in 4 cases (2.6%), 1 cases (0.6%), 4 cases (2.6%), and 4 cases (2.6%), respectively. There was no perforation or death related to ERCP. Independent risk factors for complications were acute biliary pancreatitis (ABP) (P = 0.017) and Charlson Comorbidity Index (CCI) (P = 0.019). Significantly, reasons for incomplete stone removal at once were large stone (>10 mm) (P < 0.001) and higher acute physiology and chronic health evaluation scoring system (APACHE-II) (P = 0.005).ConclusionsERCP was recommended with caution in patients ≥ 85 years of age with ABP or higher CCI undergoing endoscopic biliary stone removal. In patients with ABP without cholangitis or biliary obstruction we recommend against urgent (within 48 h) ERCP. Patients with higher CCI who can tolerate ERCP can undergo rapid ERCP biliary stenting or nasobiliary implantation with later treatment of stones, and patients who cannot tolerate ERCP are treated promptly with PTCD and aggressive conservative treatment.

V03-11 NOVEL USE OF THULIUM LASER FOR THE MANAGEMENT OF BILIARY CALCULI

You have accessJournal of UrologyCME1 May 2022V03-11 NOVEL USE OF THULIUM LASER FOR THE MANAGEMENT OF BILIARY CALCULI Akshay Reddy, Nicholas Freidberg, and Patrick Mufarrij Akshay ReddyAkshay Reddy More articles by this author , Nicholas FreidbergNicholas Freidberg More articles by this author , and Patrick MufarrijPatrick Mufarrij More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002539.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: We present the case of a 60-year-old female who underwent percutaneous endoscopic laser lithotripsy using thulium laser technology for removal of multiple complex biliary stones. Initial symptoms began six months prior, warranting workup for choledocholithiasis and pancreatitis. Multiple ERCP and ERCP/percutaneous rendezvous procedures were attempted, but unsuccessful due to massive stone size and burden. The patient was left with an IR-placed 20-French Bentec tube serving as a biliary drain. The next month, she presented to our institution for return of abdominal symptoms and rapidly developed septic shock. Following recovery, the patient underwent laparoscopic converted to open pancreatic debridement and cholecystectomy with removal of large common bile duct calculi. She subsequently developed failure to thrive and poor nutritional status requiring TPN feeding post-operatively. The accompanying video case report aims to describe the definitive management of complicated biliary stones with the use of the thulium laser. METHODS: Percutaneous access to the biliary tree was co-managed by interventional radiology and re-dilated prior to endoscopy with an Amplatz dilating sheath to 24-French. Upon placement of a flexible cystoscope into the biliary tract, several stones were identified. The 200- and 365-micron Soltive Thulium laser fibers were utilized at a frequency of 50Hz with a pulse energy of either 0.2 or 0.4J (power 10W and 20W, respectively) to fragment stones. Extraction of fragments through the transhepatic sheath was facilitated with the use a 1.7-French 8mm N-gage Cook Nitonol basket or pushed forward through the ampulla with the endoscope and gentle sterile saline irrigant. Exit endoscopy was performed without presence of any residual calculi. RESULTS: Two-week follow-up cholangiogram demonstrated moderate common bile duct narrowing with rapid flow of contrast into the duodenum and without the previous obstruction. The percutaneous drain was then removed. Compositional stone analysis was significant for cholesterol (90%) and calcium bilirubinate (10%). Microbiology demonstrated growth of Seratia marcescens with fluoroquinolone, ceftriaxone and penicillin-class resistance and Enterococcus sensitive to vancomycin and ampicillin. CONCLUSIONS: As described in our case and video, the use of thulium laser fiber was effective and safe in the removal of complex biliary stones refractory to alternative management options. This outcome is consistent with technical benefits seen in the setting of nephrolithiasis. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e204 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Akshay Reddy More articles by this author Nicholas Freidberg More articles by this author Patrick Mufarrij More articles by this author Expand All Advertisement PDF DownloadLoading ...

S3483 Recurrent Pyogenic Cholangitis

Introduction: Recurrent pyogenic cholangitis is a chronic infective process characterized by recurrent attacks of acute bacterial cholangitis, in the setting of intrahepatic biliary ductal dilation and strictures, traditionally seen in South East Asia. Case Description/Methods: We present a 39 year old female who immigrated to the United States from Burma referred to gastroenterology clinic for abnormal liver tests and computed topography (CT) scan. Patient also reported intermittent right upper quadrant abdominal pain, fatigue and decreased appetite. Labs were significant for mildly elevated aspartame transferase (AST), alanine transferase (ALT) and alkaline phosphatase (AP). CT and magnetic resonance cholangiopancreatography (MRCP) were notable for intrahepatic biliary ductal dilation with multiple non-enhancing filling defects suggestive of stones or sludge, most pronounced in the left lobe of the liver and left hepatic lobe atrophy. Common bile duct was non-dilated without stones, sludge, wall thickening or abnormal enhancement. Liver elastography was performed which revealed cirrhosis. Patient did not have evidence of acute infection at this time but overall clinical presentation was consistent with recurrent pyogenic cholangitis. Discussion: Treatment options for recurrent pyogenic cholangitis include antibiotic therapy with signs of sepsis, removal of extrahepatic biliary stones via endoscopic retrograde cholangiopancreatography, decompression of intrahepatic biliary system via percutaneous biliary drainage and less likely surgical removal of diseased liver segment and potential liver transplantation. After discussion between an advanced endoscopist, general gastroenterologists, interventional radiologists and surgeons, she was started on ursodeoxycholic acid with plan for antibiotic therapy if evidence of acute infection. She will continue surveillance MRCP every 6 months for evaluation of hepatocellular carcinoma and cholangiocarcinoma.Figure 1.: Patient's CT image demonstrating intrahepatic biliary ductal dilation with hyperdense material concerning for biliary sludge, chronic obstruction of the left intrahepatic biliary tree and left hepatic lobe atrophy.

Digital single-operator cholangioscopy in treating difficult biliary stones: results from a multicenter experience.

In clinical practice, standard endoscopic treatment of biliary stones fails in up to 10% of patients, and more invasive procedures such as percutaneous trans-hepatic interventions or surgery might become necessary. The aim of this multicenter retrospective study, based on prospectively-collected data, was to evaluate both the efficacy and the safety of digital-single operator cholangioscopy (D-SOC) to treat difficult biliary stones in cases with a previous failure of conventional endoscopic methods. Only patients with a previous failure of endoscopic standard treatment and a D-SOC-based biliary stone treatment using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) were included. The primary endpoint was to evaluate the stone clearance rate per procedure and per patient. Out of 1258 ERCP performed at our centers, 31 cholangioscopes in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL. A complete biliary stone removal was achieved in 67.7% (21/31) of all procedures including initial and repeated examinations, while in 35.4% (11/31) of all procedures an incomplete removal was accomplished of which 36.3% had a partial stone removal. In 22 procedures EHL was adopted as techniques to fragment and remove biliary stones, while in 9 procedures LL was used. In both the techniques, the complete stone removal rate and the incomplete stone removal rate were similar (75% vs. 77.7%, P>0.05). Furthermore, the success rate of digital D-SOC to treat difficult biliary stones was assessed per patient: overall, 100% of patients with difficult biliary stones were successfully treated using D-SOC. Only one patient experienced mild cholangitis classified ad mild adverse event following ASGE (American Society of Gastrointestinal Endoscopy) lexicon. Our data indicate that digital D-SOC assisted biliary stone treatment is highly efficient for the treatment of difficult biliary stones even in such patients in whom previous conventional endoscopic methods to treat biliary stones have failed. Therefore, D-SOC might be considered the new standard of care for these patients, being both, effective and safe.

Successful biliary stone removal after resolution of post-endoscopic sphincterotomy papillary stenosis using temporary covered metal stent placement.

Successful biliary stone removal after resolution of post-endoscopic sphincterotomy papillary stenosis using temporary covered metal stent placement.

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.

Performance of digital single-operator cholangiopancreatoscope for biliopancreatic diseases in real life: results from a prospective multicenter study

Objectives Peroralcholangio-pancreatoscopy (POCP) is used for diagnosis and treatment of biliopancreatic disease when standard endoscopy (ERCP) or pre-operative imaging workup failed. We aimed to evaluate the diagnostic and therapeutic performance of POCP in complex biliary and pancreatic diseases. Materials and methods Patients with indeterminate biliary or pancreatic duct (PD) strictures, and patients with failure of complex biliary or pancreatic stones removal, were enrolled (six centers). The primary endpoint evaluated malignancy diagnostic performances (accuracy, sensitivity, specificity) and therapeutic performances (biliary or pancreatic stones extraction). Secondary endpoints evaluated: technical success in lesion visualization, ease of maneuvering, image quality and 30-days complications. Results From November 2016 to March 2018, 66 patients were included: 29/37 women/men, median age (IQR): 73 (64–82). Fifty-three patients had diagnostic POCP and 13 patients therapeutic POCP. One endoscopist with one or two endoscopy nurses performed 94% of the POCP. The ‘POCP visual impression’ of malignancy showed 92.0% sensitivity, 92.9 % specificity and 92.5 % overall accuracy compared with the final diagnosis. ‘POCP-guided samples histological analysis’ showed 75.0 % sensitivity and 91.6% specificity. The technical success for lesion visualization was 98.5%. The median VAS scores for insertions in bile and PD were respectively 9.0 (8.1–9.6) and 9.0 (8.8–10.0). Median VAS score for access to the lesion and image quality were respectively 9.0 (7.7–9.6) and 9.0 (7.9–9.7). Only three 30-day minor complications occurred without any major complications. Conclusions POCP was an effective, safe and easy-to-use tool in routine clinical practice for the management of complex diagnostic and therapeutic biliary and pancreatic diseases (NCT03190343).

Crush and removal of biliary stones by peroral direct cholangioscopy and W-shaped grasping forceps after hepaticojejunostomy.

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S2330 Altered Anatomy ERCP Using a Novel Dynamic Rigidizing Overtube

INTRODUCTION: Biliary stone removal is challenging in patients with surgically altered anatomy. Double Balloon Enteroscopy (DBE) has been used to assist ERCP with cannulation, but it is often difficult and channel size is suboptimal for ERCP equipment. Antegrade EUS-guided techniques can sometimes be used but it can be challenging with higher risk. A novel dynamic rigidizing overtube is now available to help complete colonoscopy in a difficult looping colon. Normally the overtube is completely pliable, but when a vacuum is applied it becomes 15 times more rigid, providing stability and preventing looping. In this case, we use this novel overtube to complete a complex ERCP in a patient with altered anatomy. CASE DESCRIPTION/METHODS: This is a 42-year-old female with a history of iatrogenic bile duct transection during cholecystectomy who underwent Roux-en-Y Hepaticojejunostomy (HJ). Her course was complicated by HJ stricture requiring balloon-assisted enteroscopy with ERCP to place a fully-covered metal stent. After 3 months the stent was removed, but restricturing occurred 6 months later and she developed left-sided intrahepatic stone disease. Double balloon enteroscopy to reach the anastomosis became more difficult. As a result, multiple antegrade procedures via EUS placed Hepaticogastrostomy with lithotripsy were used to treat accessible intrahepatic stones, but several more remained. To facilitate further endoscopic procedures, a shortcut was made using laparoscopic revision to create a new entero-enterostomy from the proximal jejunum to the pancreaticobiliary (PB) limb. Repeat enteroscopy with a slim colonoscope failed to enter the PB limb despite multiple attempts due to difficult angulation and looping in the stomach. A dynamic rigidizing overtube was then used to assist with enteroscopy to reach the HJ. The rigidizing overtube, placed over the colonoscope, allowed the scope to advance to the HJ without looping in the stomach and provided improved control up the ascending PB limb. The colonoscope then deployed a stone extraction balloon to remove biliary duct stones. Cholangiogram confirmed stone removal and bile duct clearance. DISCUSSION: This case demonstrates the use of a rigidizing overtube to prevent looping and assist with complex stone removal via ERCP in altered anatomy. Such a device may be useful in other altered anatomy ERCP cases when anterograde approaches fail and a luminal approach is required.Figure 1.: Demonstration of rigidizing overtube. Overtube is advanced over colonoscope to its hub. Normally it is flexible, providing for normal movement during endoscopy. When a vacuum is applied it allows 1 to 1 movement, providing stability and reducing looping.Figure 2.: Stone removal with visible filling defect distal to injected contrast. Stone was removed using an extraction balloon via colonoscope and clearance was confirmed with a repeat cholangiogram.

Cholangioscopy-guided basket retrieval of impacted stones.

ERCP remains the primary method of removing bile duct stones.1Chathadi K.V. Chandrasekhara V. Acosta R.D. et al.The role of ERCP in benign diseases of the biliary tract.Gastrointest Endosc. 2015; 81: 795-803Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar Standard ERCP techniques, including endoscopic sphincterotomy with balloon sweeping or basket extraction, carry a >90% success rate in removing stones; however, large or impacted stones may present a particularly challenging scenario for the endoscopist.2Carr-Locke D.L. Therapeutic role of ERCP in the management of suspected common bile duct stones.Gastrointest Endosc. 2002; 56: S170-S174Abstract Full Text Full Text PDF PubMed Google Scholar Alternative solutions include the use of mechanical lithotripsy or cholangioscopy-guided methods, such as electrohydraulic or laser lithotripsy. However, stones may be in a position in which extraction by conventional balloon or basket under fluoroscopic guidance may be difficult (eg, in the intrahepatic ducts). The SpyGlass Retrieval Basket (Boston Scientific, Marlborough, Mass, USA) can be inserted through the SpyGlass cholangioscope (Boston Scientific) to allow for capture and removal of stones under direct visualization.3Fejleh M.P. Thaker A.M. Kim S. et al.Cholangioscopy-guided retrieval basket and snare for the removal of biliary stones and retained prostheses.VideoGIE. 2019; 4: 232-234Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar This retrieval basket represents the second iteration of the device; the first iteration was challenging to open adequately. In Video 1 (available online at www.VideoGIE.org), we demonstrate the technique of using this novel device in removing difficult-to-retrieve stones under cholangioscopy guidance. An ERCP is performed using the standard technique with cannulation of the bile duct and cholangiogram, upon which several stones, including 1 in an intrahepatic duct, are visualized. After sphincterotomy, attempts to remove the intrahepatic duct stone with a balloon are unsuccessful because the catheter cannot be advanced past the stone. The cholangioscope is then inserted over the guidewire into the bile duct. Upon visualization of the stone, which appears impacted against upstream ductal mucosa (Fig. 1), the retrieval basket is advanced (exiting at the 5 o’clock position) upstream of the stone (Fig. 2). The basket is then opened with a gentle to-and-fro motion to enclose and dislodge the impacted stone. The basket can then be slightly closed to ensure an adequate hold on the stone (Fig. 3). In this case, some fragmentation of the stone occurs when the basket is closed; once the stone is captured, the cholangioscope is withdrawn transpapillary for stone extraction (Fig. 4). Irrigation through the cholangioscope is then performed to release any debris from the basket before closure and reuse. The cholangioscope is inserted back into the bile duct to ensure all stones have been removed, with complete clearance confirmed on cholangiogram (Fig. 5).Figure 2Retrieval basket positioned inferior to the impacted stone before opening and capture.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Stone enveloped within basket.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Stone within retrieval basket withdrawn into the duodenum by withdrawal of the cholangioscope.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Final cholangiogram demonstrating complete clearance of all stones.View Large Image Figure ViewerDownload Hi-res image Download (PPT) We have used the retrieval basket under direct visualization in 5 patients: 3 patients with bile duct stones and 2 patients with pancreatic duct stones. In all 5 patients, use of the retrieval basket was successful in removing stones that were not extracted with a conventional balloon or basket. None of the 5 patients had any adverse events, such as bleeding, perforation, or pancreatitis. No device malfunctions occurred, and there were no instances of inability to release the stone from the basket. Video 1 illustrates the use of a cholangioscopy-guided retrieval basket to remove impacted stones from the bile duct. Use of this device allowed disimpaction of the stones and precise capture under direct visualization, which may be useful in cases in which the wire cannot be advanced upstream of a stone or when the extraction balloon, given the catheter tip distance from the balloon, is ineffective in dislodging the stone. Larger future studies should examine the efficacy of this technique in removing both bile and pancreatic duct stones refractory to conventional extraction techniques.

Endoscopic papillary balloon dilatation less than three minutes for biliary stone removal increases the risk of post-ERCP pancreatitis.

The adequate duration for EPBD was unclear. Therefore, we aimed to investigate the effect of balloon dilatation duration of EPBD on the occurrence of PEP. One hundred and ninety-eight patients with common bile duct (CBD) stone treated by EPBD were retrospectively recruited. The dilatation duration was determined according to adequate opening of the biliary orifice without bleeding. The clinical outcomes and complications of EPBD were recorded. We stratified the patients according to dilatation duration (Group A, <3 minutes; Group B, 3-5 minutes; Group C, ≥5 minutes). The group C patients had a higher proportion of large CBD stones (stones ≥10 mm) (33.3% vs. 26.8% vs. 53.5%, p = 0.01). Patients in group A had a significantly higher PEP rate than patients in group B (13.3 vs. 3.1, p = 0.032). There were no significant differences in perforation and bleeding rate among the three groups. Univariate and multivariate analyses showed that a dilatation duration of <3 minutes, CBD diameter < 10 mm and age ≤ 75 years were independent risk factors of PEP in post-EPBD patients. In patients receiving EPBD, dilatation duration <3 minutes, lower CBD diameter, and younger age were independent risk factors of PEP.