Retained Bile Duct Stones Research Articles

1228 Predictors of Re-Intervention Following Index Cholecystectomy

Abstract Aim Index Cholecystectomy (IC) is safe and reduces patient morbidity. However, IC can be challenging due to inflammation of hepatocystic triangle, increasing the risk of postoperative complications. Study was conducted to evaluate factors influencing postoperative complications following IC. Method Retrospective review of consecutive IC performed as a primary procedure was carried out between February 2021 and July 2022 in our trust. Primary outcome was postoperative Grade 3 Clavien-Dindo (CDC) complication, in comparison to patients with uncomplicated recovery. Pre-operative factors including age, CRP, WBC, LFT, surgeon grade, modality (laparoscopic/open) and number of previous admissions were included for analysis. Categorical and continuous data were analysed using Chi-Square and Mann-Whitney-U tests respectively. P-value <0.05 was statistically significant. Results 100 IC were included. Most IC were consultant-led [80/100(80%)]. 11/100(11%) patients developed Grade 3 CDC complication; 4/100(4%) bile leak requiring ERCP and stent insertion, 3/100(3%) post-operative collection requiring radiological-assisted drainage, 2/100(2%) retained bile duct stones requiring ERCP, 1/100(1%) incision and drainage of port site seroma and 1/100(1%) biloma requiring laparoscopic washout. Re-intervention was common in older patients (61±18years vs 55±22years,p = 0.04) and higher median peak CRP levels (312±178 vs 154±284,p = 0.01). There were no differences in LFT parameters, number of previous admissions or timing of operation from day of admission between the two groups. Conclusions Age>65 and higher pre-operative CRP were associated with increased risk of postoperative procedural intervention. Larger prospective studies are needed to confirm these findings. Surgeons should consider these factors for consenting and risk assessment purposes.

FTP5.10 Predictors of re-intervention following index cholecystectomy

Abstract Aim Index Cholecystectomy (IC) is safe and reduces patient morbidity. However, IC can be challenging due to inflammation of hepatocystic triangle, increasing the risk of postoperative complications. Study was conducted to evaluate factors influencing postoperative complications following IC. Method Retrospective review of consecutive IC performed as a primary procedure was carried out between February 2021 and July 2022 in our trust. Primary outcome was postoperative Grade 3 Clavien-Dindo (CDC) complication, in comparison to patients with uncomplicated recovery. Pre-operative factors including age, CRP, WBC, LFT, surgeon grade, modality (laparoscopic/open) and number of previous admissions were included for analysis. Categorical and continuous data were analysed using Chi-Square and Mann-Whitney-U tests respectively. P-value <0.05 was statistically significant. Results 100 IC were included. Most IC were consultant-led [80/100(80%)]. 11/100(11%) patients developed Grade 3 CDC complication; 4/100(4%) bile leak requiring ERCP and stent insertion, 3/100(3%) post-operative collection requiring radiological-assisted drainage, 2/100(2%) retained bile duct stones requiring ERCP, 1/100(1%) incision and drainage of port site seroma and 1/100(1%) biloma requiring laparoscopic washout. Re-intervention was common in older patients (61±18years vs 55±22years, p=0.04) and higher median peak CRP levels (312±178 vs 154±284, p=0.01). There were no differences in LFT parameters, number of previous admissions or timing of operation from day of admission between the two groups. Conclusion Age>65 and higher pre-operative CRP were associated with increased risk of postoperative procedural intervention. Larger prospective studies are needed to confirm these findings. Surgeons should consider these factors for consenting and risk assessment purposes.

Successful Treatment With Baricitinib in a Patient With Refractory Eosinophilic Fasciitis.

<h3>BACKGROUND</h3> Extracorporeal shockwave lithotripsy (ESWL) has been used since the mid-1980s to fragment bile duct stones which cannot be removed endoscopically. Early machines required general anaesthesia and immersion in a waterbath. <h3>AIMS</h3> To investigate the effectiveness of the third generation Storz Modulith SL20 lithotriptor in fragmenting bile duct stones that could not be cleared by mechanical lithotripsy. <h3>METHODS</h3> Eighty three patients with retained bile duct stones were treated. All patients received intravenous benzodiazepine sedation and pethidine analgesia. Stones were targeted by fluoroscopy following injection of contrast via a nasobiliary drain or T tube. Residual fragments were cleared at endoscopic retrograde cholangiopancreatography. <h3>RESULTS</h3> Complete stone clearance was achieved in 69 (83%) patients and in 18 of 24 patients (75%) who required more than one ESWL treatment. Stone clearance was achieved in all nine patients (100%) with intrahepatic stones and also in nine patients (100%) referred following surgical exploration of the bile duct. Complications included six cases of cholangitis and one perinephric haematoma which resolved spontaneously. <h3>CONCLUSION</h3> Using the Storz Modulith, 83% of refractory bile duct calculi were cleared with a low rate of complications. These results confirm that ESWL is an excellent alternative to surgery in those patients in whom endoscopic techniques have failed.

Tu1430 Single Operator Cholangioscopy for Endoscopic Treatment of Retained Bile Duct Stones and Results From a Large Multi-National Registry

Tu1430 Single Operator Cholangioscopy for Endoscopic Treatment of Retained Bile Duct Stones and Results From a Large Multi-National Registry

Is it time to write obituary for open choledocholithotomy in the present era of endoscopic management? Outcome of surgery for failed endoscopic extraction, retrospective study

Background: Between 05 to 20 percent of patients undergoing cholecystectomy for gallstones, have choledocholithiasis. Treatment of the common bile duct (CBD) stones can be conducted as open cholecystectomy and open CBD exploration or laparoscopic cholecystectomy plus laparoscopic CBD exploration (LC + LCBDE) versus pre- or post-cholecystectomy endoscopic retrograde cholangiopancreatography (ERCP) in two stages, usually combined with either sphincterotomy or sphincteroplasty (papillary dilatation) for CBD clearance. The merits and demerits of individual techniques are yet to be settled.Methods: We reviewed the outcome of patients operated at our centre after failed endoscopic clearance of CBD stones. Over a period of 03 years, total 2145 laparoscopic/open cholecystectomies were performed at our institute. In the same time period, 14 patients (06 males and 08 females) presented with choledocholithiasis after failed ERCP extraction (median age 59 years, range 29-62 years). All the patients had undergone ERCP and ± sphincterotomy/sphincteroplasty with failed clearance. None of the patient had undergone a cholecystectomy previously.Results: We performed open choledocholithotomy with T-tube drainage plus cholecystectomy in all the patients. There were no deaths and only one major complication. Surgery resulted in complete duct clearance in 93% of patients.Conclusions: Open surgery can be performed safely and effectively in patients with retained bile duct stones and surgery can be offered as primary modality of treatment over combined endoscopic management after appropriated patient selection.

USES OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN THE MANAGEMENT OF BILE DUCT STONES IN KURDISTAN CENTER FOR GASTROENTEROLOGY AND HEPATOLOGY

Objectives&#x0D; The purpose of this study is to document the extent of pre and post-cholecystectomy retained bile duct stones in our region with evaluation of the endoscopic retrograde cholangio pancreatography role in their management.&#x0D; Design&#x0D; Retrospective study.&#x0D; Patients and Methods&#x0D; This retrospective case series was carried out in Kurdistan center for gastroenterology and Hepatology in Sulaimani city–Iraq from January 2014 to January 2015. The records of 486 patients were retrospectively evaluated to collect demographic, clinical and procedure related data.&#x0D; Results&#x0D; The mean age was 51 years (range14-88 years).The female : male ratio was 2.01:1 with females constituted 325 (66.87%) while males constituted 161 (33.12%).Less than quarter of the patients were referrals from Iraqi governorates other than Sulaimani governorate. The mean duration of the ERCP procedure was 27.5 min. Deep cannulation was successful in 452 (93.o1%) patients. There was 34 (6.99%) failure of cannulation. In cases that had successful cannulation a cholangiogram was obtained which showed bile duct dilatation. Endoscopic sphincterotomy is almost done in all cases before stone extraction, and it is an adjunct for stone removal which is done by basket or balloon. It was performed in 285 (84.2%) patients, followed by stone extraction in 341 (96.05%) patients, stenting in 208 (45.51%). The most common complications reported in this study were pancreatitis, bleeding and cholangitis. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones.&#x0D; Conclusion&#x0D; Despite its associated morbidity and risk of mortality, ERCP (Endoscopic Retrograde Cholangio Pancreatography) is an important method in managing pre and post cholecystectomy choledocholithiasis. Our indications, interventions and complications rates are comparable to those reported in other countries.

Intra-cholecystic approach for laparoscopic management of Mirizzi's syndrome: A case series.

INTRODUCTION:Laparoscopic management of patients with Mirizzi's syndrome (MS) is not routinely recommended due to the high risk of iatrogenic complications.PATIENTS AND METHODS:Intra-cholecystic (IC) or inside-gall bladder (GB) approach was used for laparoscopic management of 16 patients with MS at a tertiary care referral centre in North India from May 2010 to August 2014; a retrospective analysis of prospectively collected data was performed.RESULTS:Mean age was 40.1 ± 14.7 years, the male-to-female ratio was 1:3, and 9 (56.25%) patients had type 1 MS (MS1) and 7 (43.75%) had type 2 MS (MS2) (McSherry's classification). The laparoscopic intra-cholecystic approach (LICA) was successful in 11 (68.75%) patients, whereas 5 patients (31.25%) required conversion to open method. Median blood loss was 100 mL (range: 50-400 mL), and median duration of surgery was 3.25 h (range: 2-7.5 h). No major complications were encountered except 1 patient (6.5%) who required re-operation for retained bile duct stones. The final histopathology report was benign in all the patients. No remote complications were noted during a mean follow-up of 20.18 months.CONCLUSION:LICA is a feasible and safe approach for selected patients with Mirizzi's syndrome; however, a low threshold for conversion is necessary to avoid iatrogenic complications.

Topical nitrate drip infusion using cystic duct tube for retained bile duct stone: A six patients case series

A retained bile duct stone after operation for cholelithiasis still occurs and causes symptoms such as biliary colic and obstructive jaundice. An endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy (EST), followed by stone extraction, are usually an effective treatment for this condition. However, these procedures are associated with severe complications including pancreatitis, bleeding, and duodenal perforation. Nitrates such as glyceryl trinitrate (GTN) and isosorbide dinitrate (ISDN) are known to relax the sphincter of Oddi. In 6 cases in which a retained stone was detected following cholecystectomy, topical nitrate drip infusion via cystic duct tube (C-tube) was carried out. Retained stones of 2-3 mm diameter and no dilated common bile duct in 3 patients were removed by drip infusion of 50 mg GTN or 10 mg ISDN, which was the regular dose of intravenous injection. Three other cases failed, and EST in 2 cases and endoscopic biliary balloon dilatation in 1 case were performed. One patient developed an adverse event of nausea. Severe complications were not observed. We consider the topical nitrate drip infusion via C-tube to be old but safe, easy, and inexpensive procedure for retained bile duct stone following cholecystectomy, inasmuch as removal rate was about 50% in our cases.

Biliary ascariasis: Mimicker of retained bile duct stone

Biliary ascariasis: Mimicker of retained bile duct stone

Cholangioscopy using a new type of cholangioscope for the diagnosis of biliary tract disease: a case series

We present an initial report regarding the clinical usefulness of peroral cholangioscopy, using a new type of cholangioscope, the Polyscope. Peroral cholangioscopy was performed in four patients with strictures after orthotopic liver transplantation (OLT) which were suspected of being ischemic biliary lesions, in three with indeterminate biliary strictures, in three with suspected retained bile duct stones, and in two for evaluation of the intraductal spread of adenomatous tissue after an ampullectomy. In all cases peroral cholangioscopy was performed successfully without complications. On the basis of direct viewing and/or tissue sampling a correct diagnosis was reached in all cases: in all patients who underwent OLT the strictures were not ischemic; the indeterminate strictures were all benign; and, in patients with suspected stones, complete clearance was confirmed. Intraductal spread was confirmed in one patient and excluded in the other. In our experience, peroral cholangioscopy using a Polyscope is a safe and effective method for diagnosing bile duct lesions.

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.

Laparoscopic cholecystectomy and laparoscopic common bile duct exploration in treatment of cholecvstolithiasis and choledocholithiasis

Objective To study the use of laparoscopic cholecystectomy (LC) and laparoscopic common bile duct exploration (LCBDE) in patients with cholecystocholedocholithiasis.Methods From July 2006 to June 2010,127 patients with cholecystocholedocholithiasis were treated either by LC+LCBDE (n=78) or LC+endoscopic sphincterotomy (EST,n=49).The treatment success rate,complications,retained bile duct stones rate,recovery of gastrointestinal function and hospital-stay were retrospectively analyzed.Results The LCBDE+ LC group:The operative success rate was 94.87 ％.The incidence of postoperative complications was 5.41 ％.The EST+ LC group:Complete removal of bile duct stones was achieved in 46 of 48 patients (95.92％).The incidence of postoperative complications was 12.77％.There was a significant difference in the incidences of postoperative complications between the EST+ LC group and the LCBDE+ LC group (P＜0.05).The operative time and the cost for hospital stay between the two groups were significantly different (P＜0.05).After a follow-up of 3.2 years (mean,range 1-5 years),there was no significant difference in long-term complications such as bile duct recurrent stones,duodenal papilla stenosis and cholangitis between the two groups (P＜0.05).Conclusions LCBDE was a safe,efficacious and feasible minimal invasiveness treatment for cholecystocholedocholithiasis.Primary closure of common bile duct in selected cases brought additional benefits to the minimal invasive technique. Key words: Cholecystolithiasis; Choledocholithiasis; Laparoscopic common bile duct exploration

Holmium laser lithotripsy under direct peroral cholangioscopy by using an ultra-slim upper endoscope for patients with retained bile duct stones (with video)

Direct peroral cholangioscopy (POC) by using an ultra-slim endoscope provides direct visualization of the bile duct and allows for therapeutic intervention. Holmium laser lithotripsy can be effective for retained bile duct stones, but it requires direct visualization during the procedure for safe and effective fragmentation. Direct POC by using an ultra-slim endoscope may facilitate holmium laser lithotripsy. To evaluate the feasibility, success rates, and complications of holmium laser lithotripsy under direct POC by using an ultra-slim endoscope for retained bile duct stones. Observational clinical feasibility study. Tertiary-care referral center. This study involved 13 patients with retained bile duct stones whose treatment failed by a conventional lithotripsy method involving mechanical lithotripsy. Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope. Success rate of complete stone removal and procedure-related complications. Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was successful in 11 of 13 patients (84.6%). Although direct POC was successful, holmium laser lithotripsy failed in 2 patients because of inaccurate targeting of the laser fiber to stones. There were no procedure-related complications except one case of mild pancreatitis. A small number of patients and no comparison with other lithotripsy systems. Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was feasible and can be a safe endoscopic management method for retained bile duct stones.

Randomized Controlled Trial Comparing Single-Port Laparoscopic Cholecystectomy and Four-Port Laparoscopic Cholecystectomy

To compare short-term surgical outcomes and quality of life (QOL) between single-port laparoscopic cholecystectomy (SPLC) and classic 4-port laparoscopic cholecystectomy (CLC). There is significant interest in further reducing the trauma associated with surgical procedures. Although a number of observational studies have suggested that SPLC is a feasible alternative to CLC, there is a lack of data from randomized studies validating any benefit over CLC. Eligible patients were randomized to receive SPLC or CLC. Operative and perioperative outcomes, including cosmesis and QOL were analyzed. Forty-three patients were randomized to SPLC (n = 21) or CLC (n = 22). There were no significant differences between groups for most preoperative demographics, American Society of Anesthesiology score, gallstone characteristics, local inflammation, blood loss, or length of stay. Patients undergoing SPLC were older than those receiving CLC (57.3 years vs. 45.8 years, P < 0.05). Operative times for SPLC were greater than CLC (88.5 minutes vs. 44.8 minutes, P < 0.05). Overall and cosmetic satisfaction, QOL as determined by the SF-36 survey, postoperative complications, and post-operative pain scores between discharge and 2-week postoperative visit were not significantly different between groups. Wound infection rates were similar in both groups. The SPLC group contained 1 retained bile duct stone, 1-port site hernia, and 1 postoperative port site hemorrhage. SPLC procedure time was longer and incurred more complications than CLC without significant benefits in patient satisfaction, postoperative pain and QOL. SPLC may be offered in carefully selected patients. Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another.

Su1451 The Role of Direct PerOral Cholangioscopy for the Management of Residual Bile Duct Stones After Mechanical Lithotripsy for Retained Bile Duct Stones

BackgroundThe incidence of residual stone is considered relatively high after mechanical lithotripsy (ML). Balloon occluded cholangiography shows limited efficacy in the diagnosis and removal of residual stones. Peroral cholangioscopy using Mother-Baby system can be a useful for confirming complete extraction of bile duct stones, but has several limitations for routine use. We evaluated the role of direct peroral cholangioscopy (D-POC) using ultra slim upper endoscope in the evaluation and removal of residual bile duct stones after ML.Patients and MethodsFrom August 2008 to November 2010, 46 patients received ML for fragmentation of retained bile duct stone. After confirming complete extraction of stones by balloon cholangiography, we underwent D-POC to evaluate the residual stones or fragments. Stone removal was immediately performed under D-POC for patients with residual bile duct stones.ResultsMean maximal diameter of bile duct stone was 16.69 mm. Mean numbers of bile duct stone were 2.61. 13 of 46 patients (28.3%) were revealed residual bile duct stones with D-POC after balloon cholangiography. Mean number of residual stone were 1.38 (range: 1 ∼ 3). Mean maximum diameter of residual stone was 5.54 mm (range: 2.3 ∼ 12.0 mm). 11 of 13 patients (84.6%) with residual stones could be completely removed with basket and/or balloon catheter under D-POC.ConclusionD-POC seems to be a useful endoscopic procedure for the evaluation and extraction of residual bile duct stones or fragments after ML for the patients with retained bile duct stones. BackgroundThe incidence of residual stone is considered relatively high after mechanical lithotripsy (ML). Balloon occluded cholangiography shows limited efficacy in the diagnosis and removal of residual stones. Peroral cholangioscopy using Mother-Baby system can be a useful for confirming complete extraction of bile duct stones, but has several limitations for routine use. We evaluated the role of direct peroral cholangioscopy (D-POC) using ultra slim upper endoscope in the evaluation and removal of residual bile duct stones after ML. The incidence of residual stone is considered relatively high after mechanical lithotripsy (ML). Balloon occluded cholangiography shows limited efficacy in the diagnosis and removal of residual stones. Peroral cholangioscopy using Mother-Baby system can be a useful for confirming complete extraction of bile duct stones, but has several limitations for routine use. We evaluated the role of direct peroral cholangioscopy (D-POC) using ultra slim upper endoscope in the evaluation and removal of residual bile duct stones after ML. Patients and MethodsFrom August 2008 to November 2010, 46 patients received ML for fragmentation of retained bile duct stone. After confirming complete extraction of stones by balloon cholangiography, we underwent D-POC to evaluate the residual stones or fragments. Stone removal was immediately performed under D-POC for patients with residual bile duct stones. From August 2008 to November 2010, 46 patients received ML for fragmentation of retained bile duct stone. After confirming complete extraction of stones by balloon cholangiography, we underwent D-POC to evaluate the residual stones or fragments. Stone removal was immediately performed under D-POC for patients with residual bile duct stones. ResultsMean maximal diameter of bile duct stone was 16.69 mm. Mean numbers of bile duct stone were 2.61. 13 of 46 patients (28.3%) were revealed residual bile duct stones with D-POC after balloon cholangiography. Mean number of residual stone were 1.38 (range: 1 ∼ 3). Mean maximum diameter of residual stone was 5.54 mm (range: 2.3 ∼ 12.0 mm). 11 of 13 patients (84.6%) with residual stones could be completely removed with basket and/or balloon catheter under D-POC. Mean maximal diameter of bile duct stone was 16.69 mm. Mean numbers of bile duct stone were 2.61. 13 of 46 patients (28.3%) were revealed residual bile duct stones with D-POC after balloon cholangiography. Mean number of residual stone were 1.38 (range: 1 ∼ 3). Mean maximum diameter of residual stone was 5.54 mm (range: 2.3 ∼ 12.0 mm). 11 of 13 patients (84.6%) with residual stones could be completely removed with basket and/or balloon catheter under D-POC. ConclusionD-POC seems to be a useful endoscopic procedure for the evaluation and extraction of residual bile duct stones or fragments after ML for the patients with retained bile duct stones. D-POC seems to be a useful endoscopic procedure for the evaluation and extraction of residual bile duct stones or fragments after ML for the patients with retained bile duct stones.

S1454: Two-Step Endoscopic Papillary Dilation With Large-Diameter Balloon After Endoscopic Sphincterotomy for Retained Bile Duct Stones

Currently, endoscopic papillary dilation with large-diameter balloon (EPDLB) after endoscopic sphincterotomy (EST) for removal of large bile duct stones might present lower incidence of post-procedure pancreatitis. However, the risk of severe complications, such as bleeding and perforation, are still remained. The aim of this study was to evaluate the safety and efficacy of two-step method of EPDLB after EST for retained bile duct stones.

Direct Peroral Cholangioscopy Using an Ultra-Slim Upper Endoscope for the Treatment of Retained Bile Duct Stones

Intracorporeal lithotripsy must be used under direct visual control with an additional endoscope in order to ensure safety and precise targeting during the removal of difficult-to-extract bile duct stones using conventional methods. The currently available "mother-baby" scope system has several disadvantages. We evaluated the feasibility and efficacy of direct peroral cholangioscopy (POC) using an ultra-slim upper endoscope for electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) for the treatment of difficult-to-extract bile duct stones. A total of 18 patients who were unsuccessfully treated for common bile duct (CBD) stones using conventional endoscopy, including mechanical lithotripsy (ML), underwent EHL or LL under intraductal balloon-guided direct POC using an ultra-slim upper endoscope. The balloon catheter was used to maintain access while an ultra-slim upper endoscope was advanced directly into the bile duct. EHL or LL was performed until it became possible to capture the fragmented stones in a basket. Endoscopic removal of stone fragments by duodenoscopy was attempted in the same session. The overall success rate of bile duct clearance by lithotripsy under direct POC by a single endoscopist was 88.9% (16 of 18). Stone fragmentation under direct POC was successfully performed in nine patients using EHL and in seven patients using LL. The average number of treatment sessions required to complete stone removal was 1.6. ML was performed to complete stone removal in 5 of 18 (27.8%) patients. Procedure-related complications were not observed. Lithotripsy with EHL or LL under direct POC involving the use of an ultra-slim endoscope by a single endoscopist seems to be an effective and safe treatment for select patients with difficult-to-extract CBD stones.

Direct Peroral Cholangioscopy Using An Ultra-Slim Upper Endoscope for the Treatment of Retained Bile-Duct Stones

Background and Aims: For the bile duct stones that are difficult to extract by conventional method including mechanical lithotripsy (ML), intracorporeal lithotripsy have to be applied under direct visual control through additional endoscope system for safety and better targeting. Currently available the “mother-baby” scope system has several disadvantages. The aim of this study was to evaluate the feasibility and efficacy of direct peroral cholangioscopy (direct POC) using an ultra-slim upper endoscope for laser lithotripsy (LL) or electrohydraulic lithotripsy (EHL) for endoscopic treatment of difficult bile duct stones. Patients and Methods: A total of 12 patients with common bile duct (CBD) stones in whom conventional endoscopic treatment including ML had failed were selected and underwent EHL or LL under direct POC using an ultra-slim upper endoscope (GIF-XP260N or N260; Olympus Co., Japan). Three patients underwent overtube-assisted direct POC. Intraductal balloon guided direct POC was performed in nine patients. EHL or LL was performed until possible to capture of fragmented stone into the basket. Endoscopic removal of fragments under duodenoscopy was attempted within the same session. Failure was defined as inability to achieve stone fragmentation or bile duct clearance after fragmentation. Results: The overall success rate of bile duct clearance was 91.7% (11/12) after lithotripsy under direct POC by single endoscopist. Stone fragmentation under direct POC was successfully performed in 6 patients with EHL, and 5 patients with LL. Average attempt for complete stone removal was 1.4. ML was performed for complete stone removal in 4/11 (36.4%) patients. Procedure related complications were not observed in any patients. Conclusions: Lithotripsy under direct peroral cholangioscopy using ultra-slim endoscope by one endoscopist seems to be safe and effective endoscopic treatment for the selected group of patients with difficult CBD stones. Continuous development of endoscopes and accessories are expected to facilitate therapeutic role of direct peroral cholangioscopy.

Laparoscopic Bile Duct Reexploration for Retained Duct Stones

BackgroundFailure of endoscopic sphincterotomy (ES) for retained bile duct stones occurs in 4% to 10% of cases and was traditionally managed with open bile duct reexploration. MethodsThis study uses retrospective analysis of a consecutive series of cases of laparoscopic bile duct reexploration for retained bile duct stones after unsuccessful ES. ResultsThirty-one cases were operated over a 7-year period. Seventy percent had a previous open cholecystectomy. Ten cases were successfully treated with a transcystic approach and 19 with laparoscopic choledochotomy. Two patients were converted to open surgery. Morbidity was 3.22% with no mortality. ConclusionLaparoscopic bile duct reexploration can be safely performed and should be considered as an alternative to open surgery.

The routine use of laparoscopic ultrasound decreases bile duct injury: a multicenter study

Laparoscopic ultrasound (LUS) has been used for over 15 years to screen the bile duct (BD) for stones and to delineate anatomy during laparoscopic cholecystectomy (LC). LUS as a modality to prevent BD injury has not been investigated in a large series. This study evaluated the routine use of LUS to determine its effect on preventing BD injury. A multicenter retrospective study was performed by reviewing clinical outcome of LC in which LUS was used routinely. In five centers, 1,381 patients underwent LC with LUS. LUS was successful to delineate and evaluate the BD in 1,352 patients (98.0%), although it was unsuccessful or incomplete in 29 patients (2.0%). LUS was considered remarkably valuable to safely complete LC, avoiding conversion to open, in 81 patients (5.9%). The use of intraoperative cholangiography (IOC) varied depending on centers; IOC was performed in 504 patients (36.5%). For screening of BD stones (which was positive in 151 patients, 10.9%), LUS had a false-positive result in two patients (0.1%) and a false-negative result in five patients (0.4%). There were retained BD stones in three patients (0.2%). There were minor bile leaks from the liver bed in three patients (0.2%). However, there were no other BD injuries including BD transection (0%). Retrospectively, IOC was deemed necessary in 25 patients (1.8%) to complete LC in spite of routine LUS. LUS can be performed successfully to delineate BD anatomy in the majority of patients. The routine use of LUS during LC has obviated major BD injury, compared to the reported rate (1 out of 200-400 LCs). LUS improves the safety of LC by clarifying anatomy and decreasing BD injury.