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Background The study aimed to construct an intelligent difficulty scoring and assistance system (DSAS) for endoscopic retrograde cholangiopancreatography (ERCP) treatment of common bile duct (CBD) stones. Methods 1954 cholangiograms were collected from three hospitals for training and testing the DSAS. The D-LinkNet34 and U-Net were adopted to segment the CBD, stones, and duodenoscope. Based on the segmentation results, the stone size, distal CBD diameter, distal CBD arm, and distal CBD angulation were estimated. The performance of segmentation and estimation was assessed by mean intersection over union (mIoU) and average relative error. A technical difficulty scoring scale, which was used for assessing the technical difficulty of CBD stone removal, was developed and validated. We also analyzed the relationship between scores evaluated by the DSAS and clinical indicators including stone clearance rate and need for endoscopic papillary large-balloon dilation (EPLBD) and lithotripsy. Results The mIoU values of the stone, CBD, and duodenoscope segmentation were 68.35 %, 86.42 %, and 95.85 %, respectively. The estimation performance of the DSAS was superior to nonexpert endoscopists. In addition, the technical difficulty scoring performance of the DSAS was more consistent with expert endoscopists than two nonexpert endoscopists. A DSAS assessment score ≥ 2 was correlated with lower stone clearance rates and more frequent EPLBD. Conclusions An intelligent DSAS based on deep learning was developed. The DSAS could assist endoscopists by automatically scoring the technical difficulty of CBD stone extraction, and guiding the choice of therapeutic approach and appropriate accessories during ERCP.

Background Endoscopic sphincterotomy plus balloon dilation (ESBD) is considered to be a promising method for the removal of large common bile duct (CBD) stones. However, when compared with endoscopic sphincterotomy (EST) alone, the efficacy and safety of ESBD remain controversial. This meta-analysis aimed to compare the efficacy and safety of ESBD vs. EST for the removal of large CBD stones. Methods Electronic databases were searched up to 15 July 2018 for literature that compared ESBD with EST for the removal of CBD stones. Pooled odds ratios (ORs) of the stone clearance rate and the complication rate were used to compare the efficacy and safety of ESBD vs. EST. Results A total of 18 studies with 2789 patients were included. The results showed that the stone removal rate was much higher in the ESBD group than in the EST group, both across all endoscopic retrograde cholangiopancreatography (ERCP) sessions (OR 2.68, 95 % confidence interval [CI] 1.79 to 4.01) and during the first ERCP session (OR 2.07, 95 %CI 1.37 to 3.12). The ESBD group had fewer complications than EST alone (OR 0.63, 95 %CI 0.47 to 0.85). Moreover, the ESBD group needed less mechanical lithotripsy (OR 0.38, 95 %CI 0.24 to 0.61) and had a shorter procedure time (mean difference – 4.05, 95 %CI – 7.02 to – 1.09) than EST alone. Conclusion The efficacy and safety of ESBD were superior to those of EST for the removal of large CBD stones. Moreover, less mechanical lithotripsy and shorter procedure times were needed with ESBD to manage large stones.

Zusammenfassung Hintergrund Patienten nach Ureterorenoskopie (URS) werden nach kurzem stationären Aufenthalt entlassen, die Einschätzung der Komplikationsdichte basiert auf der Betrachtung dieses kurzen Zeitfensters. Mit Daten der prospektiven BUSTER-Studie (Bewertung der ureterorenoskopischen Steintherapie – Ergebnisse hinsichtlich Komplikationen, Lebensqualität und Steinfreiheitsrate) sollen hier der Zusammenhang der Komplikationsschwere im stationären und 30-Tages-Verlauf (30-TV) sowie Einflussfaktoren auf die Lebensqualität (LQ) nach Entlassung aus stationärer Behandlung untersucht werden. Material und Methoden 01/2015 – 04/2015 wurden an 14 deutschen Kliniken Daten von 307 Patienten mit URS als Steintherapie gesammelt. Zudem wurden Komplikationen nach Clavien-Dindo-Graden (CDG) und Angaben zur LQ 30 Tage postoperativ durch Patientenfragebögen erfasst, die von 169/307 Patienten vorlagen. Es wurden drei Subgruppen gebildet: keine Zunahme der CDG im 30-TV (n = 128), Zunahme der CDG ohne Interventionsbedarf (n = 39), Zunahme der CDG mit Interventionsbedarf (n = 2). Der Zusammenhang zwischen diesen Kategorien und den Angaben zur LQ wurde durch Rangsummenkorrelation nach Spearman (ρ) geprüft. Der Einfluss klinischer Parameter auf den Endpunkt „Zunahme der CDG im 30-TV“ wurde mit einem multivariaten logistischen Regressionsmodell untersucht. Ergebnisse Während des stationären Aufenthalts traten bei 13 Patienten (7,7 %) Komplikationen auf (meist CDG1), 30 Tage postoperativ berichteten 43 Patienten (25,4 %) über Komplikationen (davon 16 CDG2, zwei CDG3). Zwischen einer Zunahme der CDG und allen Aspekten der LQ bestand eine statistisch signifikante Korrelation, am deutlichsten bei Angaben zu Schmerzen (ρ = 0,425; p Schlussfolgerungen Betrachtungen zu URS-Komplikationen sollten über die stationäre Behandlung hinaus erfolgen, da es im 30-TV zu einer Zunahme der Komplikationsdichte korrelierend mit einer Verschlechterung der LQ kam. Ob der Verzicht auf die Stenteinlage nach URS zu einer geringeren Komplikationsdichte und besseren LQ beitragen kann, muss durch weitere Studien untersucht werden.

We report a rare case of a patient of choledocholithiasis who underwent CBD stone removal with pigtail biliary stenting four year back, presenting with proximal migration of stent piercing the left lobe of liver. The stent was removed at laparotomy, by doing hepatotomy. We discuss this unreported case of proximal migration of pigtail biliary stent through surface of left lobe of liver.

Background and study aims: Direct retrograde cholangioscopy (DRC) enables high quality video imaging of the bile ducts and allows intraductal treatment with optical control. We evaluated the feasibility, success, and complications of a new third-generation prototype cholangioscope. Patients and Methods: All consecutive patients from two tertiary endoscopy centers who had undergone DRC with the prototype were included. Indications for DRC were: evaluation of indeterminate strictures, filling defects, and complex bile duct stones. Technical success was investigated in terms of indication and treatment performed. All adverse events were recorded. Results: DRC with the prototype was performed in 74 patients. Therapeutic interventions included laser or electrohydraulic lithotripsy and stone removal, among others. The papilla was entered in 72/74 patients (97 %). The targeted bile duct segment was reached in 62 /74 patients (84 %), with an anchoring balloon catheter needed in 21/74 (28 %). Mean investigation time was 21 minutes (15 – 27 minutes) Conclusions: DRC using the prototype is feasible, safe, and attains access to the bile ducts in almost all patients, with less need of an anchoring balloon catheter compared with the standard technique and short investigation and fluoroscopy times.

Endoscopic sphincterotomy (EST) for endoscopic removal of bile duct stones is difficult in patients with a Billroth II gastrectomy. We retrospectively evaluated the usefulness of an endoscopic scissors papillotome by performing EST with subsequent endoscopic papillary balloon dilation (EPBD) for the removal of bile duct stones in 12 patients with a previous Billroth II gastrectomy. EST using the scissors papillotome was performed successfully in all patients. Endoscopic stone removal was successful in 11 patients, and lithotripsy was required in three patients. No significant procedure-related complications occurred. Preceding sphincterotomy using a scissors papillotome followed by papillary balloon dilation seems to be feasible and effective for the endoscopic removal of bile duct stones in patients with a Billroth II gastrectomy.

Interventional sialography can be used to remove stones or delayed strictures from the submandibular or parotid glands. For stone removal, short-tipped, wire retrievable baskets are predominately used. Stones in the intraglandular ducts are almost impossible to remove, while stones proximal to the anatomic genu of either the parotid or submandibular ducts are also difficult to remove. More distal stones are amenable to percutaneous extraction. Stones 20% greater than the diameter of the duct should probably not be removed percutaneously. An access sheath, in the parotid or submandibular duct, greatly aids retrieval. Additionally, strictures in the parotid or submandibular ducts can be dilated with small guidewire and balloon systems. Reasonably high technical success of between 80% and 92% is reported with balloon siloplasty.

BACKGROUND Mirizzi syndrome is a rare cause of biliary symptoms and jaundice. It describes an obstruction of the common hepatic bile duct by external compression caused by an impacted gallstone in the gallbladder neck or cystic duct. This setting is usually associated with cholecystolithiasis. CASE REPORT A 64-year-old caucasian woman with intermittent abdominal pain and newly diagnosed jaundice was admitted to our clinic. An ERC was performed a few weeks earlier because of similar complaints without jaundice. At that time there was no evidence of choledocholithiasis. Now ERC surprisingly showed a gallstone impacted in the cystic duct, leading to an external compression of the common hepatic bile duct (Mirizzi syndrome). Since an endoscopic stone extraction failed, surgical intervention was performed. A laparoscopic cholecystectomy was performed without trans-cystic stone removal. After removal of the bile duct drainage it became evident that the impacted stone was still located in the remaining part of the cystic duct. After successful endoscopic extraction of the impacted stone the patient remained free of symptoms without recurrent jaundice. CONCLUSION In rare cases Mirizzi syndrome without cholecystolithiasis can cause biliary symptoms. A close interdisciplinary cooperation is necessary in order to guarantee an excellent therapeutic management.