Treatment Of Bile Duct Stones Research Articles

ThP6.2 - Benign and malignant biliary strictures encountered during single session laparoscopic cholecystectomy and bile duct exploration. Rationalising preoperative imaging and relying on routine cholangiography can optimise outcomes

Abstract Aim To review causes, diagnostic features and operative strategies of biliary strictures discovered on routine cholangiography (IOC) during single session treatment of bile duct stones. Methods A prospective database of cholecystectomies and bile duct explorations spanning 30 years was analysed. Cross sectional imaging and ERCP play a limited role in patients with confirmed gall stones except in suspected malignancies. Results 53/6140 patients (0.86%) had strictures on IOC.Malignant Strictures 27 (%)Benign strictures 26 (%)Females18 (66.6)12 (46)Age Median7262Emergency admission24 (88.8)15 (57.7)Presentation: Jaundice22 (81.5)15 (57.7)USS: GB Thick or contracted6 (22.2)4 (15.4)Bile duct dilatation16 (59.2)14 (53.8)Suspected CBD stones23 (85.2)24 (92.3)Preoperative imaging: MRCP1 (3.7)6 (23)CT6 (22.2)4 (15.4)ERCP1 (3.7)5 (19.2)Gall bladder conditionMucocele10 (37)3 (11.5)Acute/Empyema6 (22.2)4 (15.4)Contracted5 (18.5)9 (34.6)Cholangiography abnormality:Strictures + dilated ducts12 (44.4)22 (84.6)Dilated ducts/stones/no flow15 (55.5)4 (15.4)Bile Duct Exploration:Choledochotomy17 (63)10 (38.4)Transcystic5 (18.5)11 (42.3)NONE5 (18.5)5 (19.2)Choledochoscopy21 (77.7)20 (76.9)Biliary drains13 (48)18 (69)Stents9 (33.3)3 (11.5)Operative time (median)135 min135Open conversion1 Bilioenteric anastomosis0Morbidity4 (14.8)7 (26.9)Hospital stay median1413Postoperative ERCP11 (40.7)11 (42.3)Postoperative surgery322 year survival122 Conclusions Careful clinical assessment and exclusion of risk of malignancy optimises preoperative imaging and maximise benefits of single session management of suspected CBD stones.

Endoscopic treatment of bile duct stones with benign choledochojejunal anastomotic stenosis

Endoscopic interventions for bile duct stones (BDSs) with benign choledochojejunal anastomotic stenosis (bCJS) are challenging. Therefore, we investigated endoscopic interventions for BDSs with bCJS. Seventeen patients with BDSs with bCJS were retrospectively analyzed. Patient characteristics, technical success, adverse events (AEs), and recurrence were evaluated. In 17 patients, the median diameters of the bile duct and BDSs were both 8mm. The median number of BDSs was 3. The technical success rate was 94% (16/17). Ten patients underwent balloon dilation at the choledochojejunal anastomotic site (CAS), the median diameter of balloon dilation was 10.5mm, and waist disappearance was achieved in 2. Six patients had fully covered self-expandable metal stents (FCSEMSs) with a diameter of 10mm placed at the CAS. BDSs were removed after balloon dilation or FCSEMS removal, and 6 of 16 patients were treated with a combination of lithotripsy and 5 with peroral direct cholangioscopy (PDCS). Regarding AEs, perforation at the CAS by balloon dilation occurred in 1 patient. The median follow-up was 3701 days. Nine of 16 patients (56%) had recurrence. The patients treated with a combination of PDCS at BDS removal (P= .022) and waist disappearance at the CAS by balloon dilation (P= .035) had significantly fewer recurrences. Endoscopic interventions for BDSs with bCJS are useful and relatively safe; however, long-term follow-up showed frequent recurrences. Recurrence was common in patients not treated with the combination of PDCS at BDS removal and those without waist disappearance at the CAS by balloon dilation.

Experience in the surgical treatment of bile duct stone not removed by ERCP at the Itauguá National Hospital from January to October 2022

Introducción: La coledocolitiasis es la presencia de cálculos en el colédoco como consecuencia de su migración desde la vesícula o de su formación en la vía biliar extrahepática o intrahepática. Objetivo: Determinar la conducta quirúrgica adoptada para el tratamiento de la coledocolitiasis no resuelta por CPRE. Materiales y métodos: Estudio observacional, retrospectivo, descriptivo, de corte transversal. Resultados: De los pacientes en estudio se hallaron cáculos en el 62% de las CPRE realizadas, en los cuales se pudo resolver el cuadro en 85% (151/245). La edad media fue de 56,3 ± 20,75 años con mayor predominio del sexo femenino en el 78%. En los demás pacientes la técnica quirúrgica evidenció en la mayoría se realizó cirugía abierta (22/23) y coledocotomía, más frecuentemente con rafia primaria (14/23). Un solo caso fue resuelto por laparoscopía. Conclusión: para el tratamiento quirúrgico de las coledocolitiasis se utiliza principalmente la vía abierta, y la coledocotomía con rafia primaria.

Endoscopic treatment of bile duct stones after bariatric Roux-en-Y gastric bypass through endoscopic ultrasound-directed transgastric ERCP.

Endoscopic treatment of bile duct stones after bariatric Roux-en-Y gastric bypass through endoscopic ultrasound-directed transgastric ERCP.

Invisible or negligent—EUS detection for the negative CT or/and MRCP CBD stone

Invisible or negligent—<scp>EUS</scp> detection for the negative <scp>CT</scp> or/and <scp>MRCP CBD</scp> stone

Percutaneous Management of Biliary Stones.

Bile duct stone disease is the most common causes of nonmalignant bile duct obstructions. The range of common bile duct stone formation in patients with cholecystectomy is 3 to 14.7%. Hepatolithiasis, although endemic in some parts of the world, is a rare disease that is difficult to manage. Endoscopic intervention is accepted as the first-line management of common bile duct stones. However, when the bile duct cannot be cannulated for various reasons, the endoscopic procedure fails. In this circumstance, percutaneous approach is an alternative technique for the nonsurgical treatment of bile duct stones. This article reviews the indications, technique, outcomes, and complications of the percutaneous treatment of bile duct stone disease.

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

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

Clinical Outcomes of Digital Cholangioscopy-Guided Procedures for the Diagnosis of Biliary Strictures and Treatment of Difficult Bile Duct Stones: A Single-Center Large Cohort Study

Although Spy DS (SpyGlass DS Direct Visualization System) is considered to be useful for the diagnosis of bile duct strictures and the treatment of bile duct stones, there is limited data to date validating its efficacy. We hence retrospectively evaluated the clinical outcomes of the use of Spy DS in a large number of patients. A total of 183 patients who underwent Spy DS-guided procedures for indeterminate bile duct strictures (n = 93) and bile duct stones (n = 90) were analyzed retrospectively. All patients (93/93) with bile duct strictures successfully underwent visual observation, and 95.7% (89/93) of these patients successfully underwent direct biopsy. The sensitivity, specificity, and overall accuracy were 94.7%, 83.3%, and 90.3%, respectively, for visual impression; 80.9%, 100%, and 89.2%, respectively, for histopathological analysis of a direct biopsy; and 96.5%, 91.7%, and 94.6%, respectively, for visual impression combined with biopsy. Successful visualization of the stones was achieved in 98.9% (89/90) of the patients, and complete stone removal was achieved in 92.2% (83/90) of the patients, with an average of 3.3 procedures. The adverse events rate was 17.5% (32/183; cholangitis in 15 patients, fever the following day in 25, pancreatitis in 1, hemorrhage in 1, and gastrointestinal perforation in 1). No administration of antibiotics before the procedure was found to be a statistically significant risk factor for the development of fever after the procedure (p < 0.01). Spy DS-guided procedures are effective for the diagnosis and treatment of bile duct lesions and can be performed with a low risk of serious adverse events.

Multicenter experience with digital single-operator cholangioscopy in pregnant patients.

Background and study aims The use of fluoroscopy during pregnancy should be minimized given that a clear-cut safe radiation dose in pregnancy is unknown. The role of digital single-operator cholangioscopy (D-SOC) as an alternative to standard enodoscopic retrograde cholangiopancreatography (ERCP) in pregnant patients has not been comprehensively studied. This study assessed 1 Technical success defined as performance of ERCP with D-SOC without the use of fluoroscopy in pregnant patients; 2 safety of D-SOC in pregnancy; and 3 maternal and neonatal outcomes after D-SOC during/after pregnancy. Patients and methods This was an international, multicenter, retrospective study at 6 tertiary centers. Pregnant patients who underwent D-SOC for the treatment of bile duct stones and/or strictures were included. Results A total of 10 patients underwent D-SOC. Indications for ERCP were choledocholithiasis, strictures, previous stent removal, and choledocholithiasis/stent removal. Bile duct cannulation without fluoroscopy was achieved in 10 of 10 patients (100 %). Moreover, 50 % of patients (5/10) completed a fluoroless ERCP with D-SOC. Mean fluoroscopy dose and fluoroscopy time were 3.4 ± 7.2 mGy and 0.5 ± 0.8 min, respectively. One case of mild bleeding and one case of moderate post-ERCP pancreatitis occurred. The mean gestational age at delivery was 36.2 ± 2.6 weeks. Median birth weight was 2.5 kg [IQR: 2.2–2.8]. No birth defects were noted. Conclusion ERCP guided by D-SOC appears to be a feasible and effective alternative to standard ERCP in pregnant patients. It enables avoidance of radiation in half of cases.

Long-Term Outcomes of Endoscopic Treatment for Bile Duct Stones in Patients Aged ≥ 85 Years

Long-Term Outcomes of Endoscopic Treatment for Bile Duct Stones in Patients Aged ≥ 85 Years

Value of SpyGlass single-operator choledochoscopy system in the diagnosis and treatment of patients with biliary tract diseases

Objective To investigate the value of SpyGlass single-operator choledochoscopy system in the diagnosis and treatment of patients with unexplained biliary stricture, complex bile duct stones, or other biliary tract diseases. Methods A retrospective analysis was performed for the clinical data of the patients with biliary tract diseases who were diagnosed and treated with SpyGlass in The Second Affiliated Hospital of Nanjing Medical University from December 2017 to June 2020. For the patients with biliary stricture, the biliary lesions were fully visualized under the guidance of SpyGlass, and SpyBite biopsy was performed if necessary; the patients with bile duct stones were treated with SpyGlass-guided direct-view laser lithotripsy; for the patients with gallbladder disease, the cystic duct was superselected with the assistance of SpyGlass. The SpyGlass system was analyzed in terms of its sensitivity, specificity, and accuracy rate in diagnosis and treatment, lithotripsy success rate, stone clearance rate, procedure success rate, and incidence rate of complications. Results A total of 58 patients underwent SpyGlass procedure. SpyGlass was used to evaluate biliary stricture of unknown nature in 44 (76%) patients; SpyGlass visual impression had a diagnostic sensitivity of 92% (24/26), a specificity of 94% (17/18), and an accuracy of 93% (41/44), and SpyBite biopsy had a diagnostic sensitivity of 71% (15/21), a specificity of 92% (11/12), and an accuracy of 79% (26/33). SpyGlass was used for the treatment of bile duct stones in 8 patients (14%), with a lithotripsy success rate of 83% (5/6) and a stone clearance rate of 88% (7/8). A guide wire under the SpyGlass system was to superselect the cystic duct in 5 patients (9%), with a procedure success rate of 80% (4/5). In one patient (1%), SpyGlass was used to assist the removal of common bile duct stones after liver transplantation and the treatment of bile duct anastomotic stricture. A total of 5 patients (9%) experienced complications after surgery. Conclusion The SpyGlass choledochoscopy system is accurate, safe, and effective in the diagnosis and treatment of unexplained biliary stricture, complex bile duct stones, and other biliary tract diseases.

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.

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

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

Therapeutic Images of CT Image Analysis Based on 3D Visualization Technology in Patients with Hepatobiliary Stones

Objective: Paper for CT imaging in three-dimensional visualization technology for laparoscopy combined with biliary hard lens therapeutic clinical effect of extrahepatic bile duct stones were evaluated. Methods: Abdominal medical image 3D visualization software for our hospital CT imaging diagnosis and treatment of bile duct stones in 45 patients of bile duct stones three-dimensional visualization of clinical analysis and preoperative planning, and brought it into the operating room three-dimensional visualization model, guiding the implementation of the joint 3D laparoscopic biliary lithotripsy targeted hard lens. At the same time, as well as consistency with the actual hepatolithiasis distribution calculation operative 3D model visualization display; The operative time, bleeding, blood transfusion, stone clearance rate, morbidity and mortality perioperative after review stone recurrence rate was observed. Results: reproducing a three-dimensional patient model visualization liver, intrahepatic vascular anatomy of the liver bile duct stones distributed, real intraoperative and preoperative displayed three-dimensional visualization model consistent, pre-operative manner consistent with preoperative planning. Operation time (125.9±21.2) minutes, blood loss (38.8±8.5) ml, no massive hemorrhage and blood transfusion; MRCP examination by stone clearance rate was 100%; 2 biliary injury, bile leakage 1 complication the rate was 6.7%; There were no perioperative deaths. Stone recurrence two cases, the recurrence rate of 4.4%. Conclusion: The three-dimensional visualization techniques may be implemented hepatolithiasis accurate assessment of preoperative, intraoperative guidance of laparoscopic, endoscopic biliary hard gravel, stone liver resection operation, help to improve stone clearance rate, guarantee operation safety.

Management of Common Bile Duct Stones: A Comprehensive Review

Bile duct stones (BDS) are usually secondary to gallstones but may be found primarily in biliary system, although the percentage is minimal. They are usually suspected on history and clinical examination alone but symptoms may be variable ranging from asymptomatic to complications such as biliary colic, pancreatitis, jaundice or cholangitis, the latter can be life-threatening in some patients. Abnormalities in the liver function tests especially the elevated direct bilirubin and alkaline phosphatase indirectly raise the suspicion. The majority of BDS can be diagnosed by Transabdominal Ultrasound, but in some cases further imaging such as, Computed Tomography, Endoscopic Ultrasound or Magnetic Resonance Cholangiography are employed prior to endoscopic or laparoscopic removal. Approximately 90% of BDS can be removed following Endoscopic Retrograde Cholangiography (ERC) + sphincterotomy. Most of the remaining stones can be removed using mechanical lithotripsy. Patients with uncorrected coagulopathies may be treated with ERC + pneumatic dilatation of the sphincter of Oddi. Shockwave lithotripsy (intraductal and extracorporeal) and laser lithotripsy have also been used to fragment large bile duct stones prior to endoscopic removal. Despite all the minimally invasive procedures the role of open surgery for the removal of difficult or impacted stones cannot be completely forgotten. The role of medical therapy in treatment of BDS is currently uncertain. This review focuses on the clinical presentation, investigation and current management of BDS.

Surgical Techniques for the Laparoscopic Treatment of Bile Duct Stones in Patients With a History of Upper Abdominal Operations: Retrospective Cohort Study.

Few authors have studied applying the laparoscopic approach in patients with previous upper abdominal operations, but no comparison has been made between laparoscopic and open approaches in patients with previous upper abdominal operations. This article aims to introduce surgical techniques and details in treatment to surgeons specialized in minimally invasive surgery. From January 2010 to January 2018, 460 eligible patients were divided into 3 groups and analyzed retrospectively. Group A: patients with a history of upper abdominal operations who underwent laparoscopy (n=124); group B: patients without a history of upper abdominal operations who underwent laparoscopy (n=140); and group C: patients with a history of upper abdominal operations who underwent an open operation (n=196). Group A was the experimental group; groups B and C served as the control groups. No significant difference was found between groups A and B. Significant differences were found between groups A and C in estimated blood loss (258.3±67.2 vs. 424.7±103.7 mL, P<0.001), postoperative hospitalization (5.7±2.3 vs. 10.2±3.1 d, P<0.001), and postoperative complications (16.1% vs. 42.9%, P=0.013). The final rate of stones clearance was 100% in 3 groups. The total rate of stone recurrence was 7.8%. Laparoscopy with certain surgical techniques was feasible, effective, and advantageous for patients with previous upper abdominal operations by experienced surgeons. It is necessary for surgeons to have advanced skills and surgical techniques to achieve a successful laparoscopy.

Two-stages using endoscopic retrograde cholangio-pancreatography procedures versus single stage laparoscopic management for concomitant gallstones and common bile duct stones

Background: Laparoscopic common bile duct exploration (LECBD) has been proven to be a safe, reliable, and effective treatment for common bile duct (CBD) stones and has gained wider acceptance. Endoscopic retrograde cholangio-pancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is safe and efficient method that has been usually used for the treatment of bile duct stones. The aim of this study is to compare the outcome of management of concomitant gallstones and common bile duct by two stage (ERCP+LC) versus one stage (LECBD+LC).Methods: This study included 150 patients with concomitant gallstones and CBD stones who were treated at sohag university hospital from July 2017 to December 2018. Results were statistically analysed.Results: The success rates of laparoscopic CBD exploration and ERCP for clearance of CBD were similar (Group A 96% vs. Group B 97.3%). The mean operative time was significantly longer in-group A (125.7±36.6 min) vs. in-group B (82.4±27.6 min), Group A as regard intraoperative complications (one patient had hemorrhage) vs. group B (2 patients hemorrhage during lap. cholecystectomy). As for conversion to other procedure 2 patients for group A vs. 3 patients for group B (conversion of LC to open).Conclusions: Single and two-stage management for uncomplicated concomitant gallbladder and CBD stones had similar success and complication rates, but the single stage strategy was better in terms of shorter hospital stay, need for fewer procedures, less morbidity, and allows earlier recovery with a reduced period of short-term disability.

Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones.

To review the current literature focusing on the indications, efficacy, and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) with or without endoscopic sphincterotomy (EST) in the treatment of bile duct stones. • EPBD without EST is associated with a higher risk of post-procedural pancreatitis and lower rate of stone clearance than EST alone. • EPBD without EST should be at least 2min in duration, and placement of a pancreatic stent and other measures to reduce pancreatitis risk should be considered. • EPBD without EST is most useful to reduce risk of bleeding in patients with coagulopathy. • EPLBD combined with EST can be used as an alternative or adjunct to mechanical lithotripsy in the removal of large or difficult bile duct stones. • EPLBD combined with EST results in fewer complications than EST alone for removal of bile duct stones.

A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave.

When conventional endoscopic treatment of bile duct stones is impossible or fails, advanced endoscopy-assisted lithotripsy can be performed by electrohydraulic lithotripsy (EHL), laser lithotripsy, or extracorporeal shock wave lithotripsy (ESWL). No systematic review has compared efficacy and safety between these techniques. A systematic search was performed in PubMed, the Cochrane Library, and EMBASE for studies investigating EHL, laser lithotripsy, and ESWL in patients with retained biliary tract stones. After screening 795 studies, 32 studies with 1969 patients undergoing EHL (n = 277), laser lithotripsy (n = 426) or ESWL (n = 1266) were included. No randomized studies were available. Although each advanced lithotripsy technique appeared to be highly effective, laser lithotripsy had a higher complete ductal clearance rate (95.1 %) than EHL (88.4 %) and ESWL (84.5 %; P < 0.001). In addition, a higher stone fragmentation rate was reported for laser lithotripsy (92.5 %) than for EHL (75.5 %) and ESWL (89.3 %; P < 0.001). The post-procedural complication rate was significantly higher for patients treated with EHL (13.8 %) than for patients treated with ESWL (8.4 %) or laser lithotripsy (9.6 %; P = 0.04). Data on the recurrence rate of the biliary tract stones were lacking. This systematic review revealed that laser lithotripsy appeared to be the most successful advanced endoscopy-assisted lithotripsy technique for retained biliary tract stones, although randomized studies are lacking.

Sa1361 CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY IN THE TREATMENT OF DIFFICULT BILE DUCT STONES- A SINGLE CENTER EXPERIENCE

Using standard techniques, the treatment of bile duct stones is highly effective in 85-90% of cases. In 5-15% the stones are classified as “difficult” due to their size, location, form, calcification or altered anatomy. For these situations alternative treatment options are needed. Cholangioscopy- guided laser- or electrohydraulic lithotripsy increases the success rate of the bile duct stones treatment up to 100%. To evaluate the efficacy, safety and cost- effectiveness of the cholangioscopy guided laser lithotripsy for the treatment of difficult bile duct stones in the context of complications, price and mean procedure time. Data was collected retrospectively from January 2016 to September 2017. All the patients had previous single-session ERCP, sphincterotomy with or without large balloon dilation and plastic stenting performed and bile duct stones were characterized as “difficult” after attempts for extraction using standard techniques or after detection of anatomical abnormalities of the biliary system /strictures/. Patients were scheduled for cholangioscopy with the SpyGlass DS system (Boston Scientific, Marlborough, MA, USA). A 200 μm single use laser fiber (Cook Medical, Bloomington, IN, USA) was positioned close to the stone and lithotripsy was performed until complete fragmentation has been achieved (Settings- 1,2 mJ, 8Hz). The procedure was followed by balloon- or basket extraction of fragments. CBD clearance was confirmed by cholangioscopy. Further interventions were rescheduled if needed. For the period a total of 16 cholangioscopy- guided holmium laser lithotripsies were performed in 14 patients. 2 complications were documented- hemobilia caused discontinuation of the procedure in a patient with essential thrombocitopaenia and a case of mild cholangitis treated with i.v. antibiotic for 5 days. Nasobiliary drainage was left for 24 hours in 2 patients, 2 patients received temporary plastic stents for cholangitis- profilaxis due to residual debris . No serious adverse events requiring surgery, blood transfusions or ICU admission were noted. Cholangioscopy guided Holmium laser lithotripsy is a safe and effective option to treat difficult bile duct stones. The early implementation avoids multiple ERCP- sessions, surgery and related complications in patients, unsuitable for standard endoscopic treatment. Carefull patient selection is needed in relation with the cost- effectiveness and procedure duration.Table 1ResultsNumber of patients14Impacted CBD stones6/14 (42,8%)CBD stones8/14 (57%)Stones in the common hepatic duct2/14 (14,2%)Intrahepatic stones3/14 (21,4%)Stones in the cystic duct1/14 (7,1%)Size of the stones10-35 mmNumber of sessions until complete clearance1,14Duration of the procedure90-180 min.Complications2/14 (14,2%) Open table in a new tab