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Background 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 multi-center 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. Methods Only patients with a previous failure of endoscopic standard treatment and a DSOC- 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 (three?) centers, 31 cholangioscopies in 21 patients were solely performed for the treatment of difficult biliary stones using EHL or LL. Results 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>.05). Furthermore, the success rate of digital DSOC 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. Conclusions In conclusion, 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.

Biliary endoscopy is underutilized by interventional radiologists and has the potential to become an effective adjunctive tool to help both diagnose and treat a variety of biliary pathology. This is particularly true in cases where endoscopic retrograde cholangiopancreatography fails or is not feasible due to surgically altered anatomy. Both preoperative clinical and technical procedural factors must be taken into consideration prior to intervention. In this article, clinical evaluation, perioperative management, and procedural techniques for percutaneous biliary endoscopy are reviewed.

Background and Aim Accurate anatomical delineation is the key before definitive repair for benign biliary stricture (BBS). The role of percutaneous transhepatic cholangiography (PTC) as a road map is less studied in the era of magnetic resonance cholangiopancreatography (MRCP). Methods A prospective observational study, performed between July 2012 and December 2013. All patients of post‐cholecystectomy BBS were evaluated with MRCP and PTC prior to definitive repair. Findings of MRCP and PTC were compared with intraoperative details. Results Thirty patients with BBS were included in the study. MRCP was performed in all but PTC was amenable in 28 of 30 (93.3%) patients. PTC was comparable to MRCP in diagnosing stricture type (96.4% vs 89.3%), intrahepatic stones (75% vs 75%), and biliary anomalies (95.6% vs 100%). Additionally, PTC revealed internal biliary fistula in 4 (85.7% vs 61.4%; P value 0.04). PTC‐related minor complications were noted in 2 (7.1%) patients. Conclusion PTC is comparable to MRCP in diagnosing the stricture type, intrahepatic biliary stones, and biliary anomalies. Though comparable to MRCP, the authors could not reveal any additional information that could change the course of management in BBS., Magnetic resonance cholangiopancreatography (MRCP) appears to be an optimum preoperative roadmap, as it yielded additional information like collections or intra‐abdominal abscess for deciding the management in benign biliary stricture (BBS). MRCP has been found to be inferior to percutaneous transhepatic cholangiography (PTC) in recognizing internal biliary fistulae. PTC was more in concordance with the intraoperative findings with respect to the type of stricture when compared with MRCP. Though PTC yielded some additional information over MRCP, it could not alter the course of management in BBS.

Endoscopic retrograde cholangiopancreatography (ERCP) is the current treatment of choice in bile duct stones. Several factors such as variant anatomy of ampulla and surgical procedures like hepaticojejunostomy limit the success of ERCP in treating bile duct stones. Percutaneous transhepatic laser lithotripsy using interventional radiologic and endourologic techniques, which is uncommon, is a reasonable treatment option in such difficult cases. It is a minimally invasive, safe procedure accompanied by a high success rate, minimal morbidity, and a short hospital stay. We report our technique and experience in a series of three patients who underwent percutaneous transhepatic biliary drainage (PTBD) followed by percutaneous transhepatic laser lithotripsy in an attempt to avoid open surgery when ERCP was technically difficult.

PURPOSE To investigate the association between the use of proton pump inhibitors (PPIs) and the risk of early biliary infection (EBI) after the placement of percutaneous transhepatic biliary stents (PTBS) in patients with unresectable malignant biliary obstruction (MBO). MATERIALS AND METHODS A total of 136 patients with unresectable MBO (82 males and 54 females) treated with PTBS were included in this multicenter retrospective study. PPIs were prescribed to MBO patients with dyspepsia. The risk factors for EBI were identified by univariate and multivariate analyses. The association between the use of PPIs and EBI was assessed by logistic analyses. RESULTS A total of 72 (53%) patients were regular users of PPIs, and 33 (24%) patients developed EBI after PTBS. Univariate and multivariate analyses revealed that diabetes (hazard ratio [HR], 20.3; 95% confidence interval [CI], 5.6-72.9; P

Background and Objective Extracorporeal shock wave lithotripsy (ESWL) for common bile duct (CBD) stones has been used in the past, but experience is limited. We report our experience of ESWL in the management of difficult CBD stones. Methods Patients with difficult-to-retrieve CBD stones were enrolled and underwent ESWL. Fluoroscopy is used to target the stones after injection of contrast via nasobiliary drain. CBD clearance was the main outcome of the study. Results Eighty-three patients were included (mean age 50.5 ± 14.5 years); these patients were mainly females (43; 51.8%). Large stones >15 mm were noted in 64 (77.1%), CBD stricture in 22 (26.5%) and incarcerated stone in 8 (9.6%) patients. Patients needed 2.1 ± 1.2 sessions of lithotripsy and 4266 ± 1881 shock waves per session. In 75 (90.3%) patients, the fragments were extracted endoscopically after ESWL, while spontaneous passage was observed in 8 (9.6%). Total CBD clearance was achieved in 67 (80.6%) patients, partial clearance in 5 (6%) and no response in 11 (13.2%). Failure of the treatment was observed in large stone with size ≥2 cm (P = 0.021), incarcerated stone (P = 0.020) and pre–endoscopic retrograde cholangiopancreatography cholangitis (P = 0.047). Conclusion ESWL is a noninvasive, safe and effective therapeutic alternative to electrohydraulic lithotripsy and surgical exploration for difficult biliary stones.

Background Peroral cholangioscopy with intraductal lithotripsy facilitates optically guided stone fragmentation of difficult biliary stones refractory to conventional endoscopic therapy. The aim of this study was to evaluate the efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones. Methods Searches of PubMed, EMBASE, Web of Science, and Cochrane databases were performed in accordance with PRISMA and MOOSE guidelines. Measured outcomes included overall fragmentation success, single-session fragmentation and duct clearance, and rate of adverse events. Sensitivity and subgroup analyses were performed based upon cholangioscopy technique and type of lithotripsy (laser versus electrohydraulic). Heterogeneity was assessed with I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. Results 35 studies were included with 1762 participants (43.4 % men; mean age 61.5 [standard deviation (SD) 11.0]). Prior cholecystectomy had been performed in 37 % of patients, with a mean number of 1.6 (SD 0.5) ERCPs performed prior to lithotripsy. Mean stone size was 1.8 (SD 0.3) cm. Peroral cholangioscopy with intraductal lithotripsy achieved an overall stone fragmentation success of 91.2 % (95 %CI 88.1 % – 93.6 %; I 2 = 63.2 %) with an average of 1.3 [SD 0.6] lithotripsy sessions performed. Complete single-session fragmentation success was 76.9 % (95 %CI 71.6 % – 81.4 %; I 2 = 74.3 %). The adverse events rate was 8.9 % (95 %CI 6.5 % – 12.2 %; I 2 = 60.6 %). Mean procedure time for peroral cholangioscopy was 67.1 (SD 21.4) minutes. There was no difference in overall fragmentation rate or adverse events; however, laser lithotripsy was associated with a higher single-session fragmentation rate and shorter procedure time compared with electrohydraulic lithotripsy. Conclusions Peroral cholangioscopy with intraductal lithotripsy appears to be a relatively safe and effective modality for difficult biliary stones.

Background and Aims: Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. Methods: A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. Results: The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. Conclusions: Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

Intraductal biliary stones can result in significant acute and long-term complications. When patients' anatomy precludes more traditional management, the interventional radiologist may be called upon to provide well-established techniques for percutaneous biliary drainage and stone removal. This can be particularly challenging when the patient has excessively mobile, impacted, large or multiple stones. Percutaneous biliary endoscopy with adjunct interventional techniques can successfully treat these patients avoiding the patient dreaded "tube for life" scenario. Direct percutaneous visualization of the biliary tree can also diagnose and provide symptomatic relief for stone-mimicking pathologic conditions such as biliary tumors. This article will review the role, technique, and considerations for percutaneous biliary endoscopy and adjunct interventions in patients with isolated and complex, biliary stone disease and stone-mimicking pathologies.

Background The percutaneous approach (PA) for management of biliary stones (BS) with or without an underlying biliary stenosis is an option for patients in whom an endoscopic approach (EA) is not possible. The aim of this study was to evaluate the efficacy of a PA in patients with BS unsuitable for an EA. Methods A retrospective review of a database was performed. Inclusion criteria included patients with benign disease, BS who had undergone a PA. The outcomes were technical success rate, short (≤90 days) and long-term (>90 days) efficacy and safety. Results A total of 91 patients enrolled were divided into those with (n = 38) or without (n = 53) a biliary stenosis. A median of 5 (IQR:3–7) treatments/patient were performed. During a median follow-up of 23 months (IQR:3–52), the median time free from recurrence was 21 months (CI:14–29). In the long term, the PA was most efficacious in those patients without a biliary stenosis with long term success in 68% of patients as compared to 36% of patients with a biliary stenosis (p = 0.003). Conclusion A PA is an effective procedure with high initial success rate, however the coexistence of stenosis affects long-term efficacy, especially in patients with chronic biliary disease.

Introduction Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an well-established endoscopic procedure for the management of biliary diseases. The use of fluoroscopy during ERCP has often raised concerns regarding potential risks from radiation exposure, particularly in complex cases. We investigated whether a new digital single-operator cholangioscopy (D-SOC) system, used adjunctively to ERCP, actually reduces patient radiation exposure. Materials and methods We retrospectively analyzed a prospective database (April 2016 to October 2018) including consecutive patients who underwent successful management of difficult-to-treat biliary stones or indeterminate biliary strictures by using either conventional ERCP (ERCP cohort) or ERCP in conjunction with D-SOC (ERCP/D-SOC cohort). The overall patient radiation exposure outcomes were compared in terms of Kerma Area Product (KAP), Fluoroscopy time (T) and the total number of films (F). Results Overall, 47 patients (mean 71.8 years, 59.6% males) were included (ERCP cohort = 29, ERCP/D-SOC cohort = 18), referred either for difficult bile duct stones (n = 36) or indeterminate biliary strictures (n = 11). The median KAP, T and F in the ERCP/D-SOC cohort were 12.3 Gycm 2 , 3.7 min and 4 films respectively, compared with 52.1 Gycm 2 , 8.4 min, and 5 films respectively in the ERCP cohort. Statistically significant differences (P = 0.0001) were found for KAP and T. Conclusions Adjunct use of a digital cholangioscopy platform appears to significantly reduce radiation exposure in patients undergoing ERCP for the management of difficult bile stones or indeterminate biliary strictures.

Background/Aims: The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP. Patients and Methods: This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded. Results: A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66–12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13–1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36–15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56–6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10–8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00–0.08) on multivariate analysis. Conclusion: A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones.

Although not common, Mirizzi's syndrome (type 1) is a differential diagnosis in a patient with cholecystitis and obstructive jaundice, after a thorough clinical assessment. The jaundice would be resolved by cholecystectomy.

A woman in her early 80s with jaundice visited our hospital. Close examination revealed that her jaundice was obstructive due to stones in the terminal portion of the common bile duct (CBD). CT showed that the terminal portion of CBD was prompted to the duodenal lumen (figure 1A, arrow). Duodenoscopy showed a smooth hemispherical mass protruding into the duodenal lumen (figure 1B), and the ampullary orifice was identified at the anal side of this mass (figure 1C). Endoscopic ultrasonography revealed cyst-like …

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89–94% and 94–95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients’ outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis.

Background Choledocholithiasis is closely associated with bacterial infection and inflammation in the bile duct. Our previous studies showed that sphincter of Oddi laxity (SOL) significantly altered the bile microbiota and might contribute to the recurrence of biliary stones. However, the direct association among SOL, the bile microbiota, and choledocholithiasis recurrence is unclear. Methods We prospectively recruited 202 patients with choledocholithiasis, and obtained bile samples from the common bile duct. We performed 16S ribosomal RNA gene analysis to characterize the bile microbiota and analyzed the risk factors for choledocholithiasis. Results Distinct bile microbial communities were identified in patients with and without SOL, with a significantly larger abundance of Rhizobiaceae in patients with SOL. Patients with SOL had a higher risk of biliary stone recurrence, with a considerably shorter recurrence time. The abundance of Clostridium was significantly higher in patients with stone recurrence. SOL [P=0.024, hazard ratio (HR) =10.800, 95% confidence interval (CI): 1.377-84.701] was an independent risk factor of choledocholithiasis recurrence. Conclusions Choledocholithiasis patients with and without SOL demonstrated significant differences in their microbial communities. SOL is a critical risk factor for the recurrence of choledocholithiasis after surgery. The presence of Clostridium may be potentially associated with the recurrence of SOL-induced choledocholithiasis.

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.

OBJECTIVE Dual-layer spectral detector computed tomography (DLCT) can detect noncalcified biliary stones. The diagnostic ability of DLCT for detecting biliary stones may be comparable to that of magnetic resonance cholangiopancreatography (MRCP). This study seeks to compare the diagnostic ability for biliary stones between these two imaging modalities. METHODS This retrospective study included 102 cases with a diagnosis of biliary stones including gallstones (n = 66) and common bile duct (CBD) stones (n = 25) or spontaneously passing CBD stones (n = 11). The reference standard used was operative findings, endoscopic retrograde cholangiopancreatography or follow-up over 6 months. In DLCT, 120-kVp images, 40-keV virtual monoenergetic images and material decomposition images were created. We compared the diagnostic ability of DLCT and MRCP for biliary stones using the McNemar's test. RESULTS The sensitivity and specificity of DLCT versus MRCP for biliary stones were 91.2% versus 95.6% and 90.9% versus 90.9%. Thus, the sensitivity and specificity were not significantly different (P = 0.25 and P = 1.0). Although in small stones (

Background and Aims Migration is a late adverse event of biliary stent placement. It occurs in 1% to 20% of cases and is associated with a diverse array of adverse events. In this article, we report our take on endoscopic extraction of proximally migrated biliary stents by the use of single-operator cholangioscopy. Methods This report includes 3 patients who were found to have proximal stent migration while being treated for biliary stones. One patient had a migrated metal stent, and the other 2 had plastic stents. Single-operator cholangioscopy was used to retrieve the stents in all patients. The SpyBite biopsy forceps accessory was used to extract the metal stent, whereas the SpyBasket and the SpySnare were used to extract the plastic stents. Results All patients underwent successful stent removal by the techniques described in this report, with no immediate adverse events, and they completed more than 4 weeks of follow-up care with no further adverse events. Conclusions Digital single-operator cholangioscopy with SpyBasket, retrieval snare, and SpyBite biopsy forceps can be useful tools to remove migrated plastic and metallic stents, respectively.

To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment. We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up. PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29–210, 95% CI 101–129) minutes; median hospital stay was 5.5 (2–42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively. PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate.

Background Single-operator cholangioscopy assisted electrohydraulic lithotripsy is the standard of care for difficult common bile duct (CBD) stones with failed clearance using standard ERCP. This technology is expensive and optimal timing of its use in terms of cost-effectiveness in the management algorithm of patients with difficult CBD stones remains unclear Aims To determine the cost-effective timing of SOC-EHL utilization in the management of difficult CBD stones Methods A decision model was developed assessing 4 strategies and progressively delayed introduction of SOC-EHL in relation to ERCP over 6-months. Difficult stones were defined as having failed CBD clearance via standard ERCP. Probability estimates for each health state were obtained from a literature systematic review. For each strategy, outpatients undergoing ERCP underwent different timings of SOC-EHL introduction from the first to the fourth ERCP and were followed for subsequent need for re-intervention, adverse events, need for surgery, and/or successful endoscopic CBD clearance. The unit of effectiveness was complete CBD clearance without need for surgery. Deterministic sensitivity analyses were performed varying all 50 model variables across ranges spanning 30% of their respective values. Costs are in 2018US$ based on US data. Results Performing SOC-EHL immediately during the first ERCP is the least expensive approach when compared to delaying SOC-EHL. This strategy costs $15,528 on average per patient with CBD clearance avoiding surgery and can save between $260 to $720 compared to the 3 other strategies, which introduce SOC-EHL during the second to the fourth ERCP. Effectiveness is clinically comparable between the four strategies ranging from 97–99%. Deterministic sensitivity analysis shows changes in the results when the ERCP complication rate (baseline probability of 6%) decreases to 4.5%, when the SOC-EHL (baseline costs of $2,450) costs more than $2,670, or when the ERCP facility fees (baseline costs of $4,292) are less than $3,425. In all 3 scenarios, delaying the first SOC-EHL use to the fourth procedural attempt becomes the dominant strategy. Variations of the other 47 variables did not alter results. Conclusions Although SOC-EHL is expensive, this analysis demonstrates that among patients who have failed a prior attempt at stone extraction, utilization of SOC-EHL at the next (first subsequent) ERCP is less costly when compared to its delayed introduction. However, postponing the use of SOC-EHL to the fourth ERCP could be identified as the most cost-effective strategy when facility fees or ERCP complications rates are below certain thresholds, or when the costs of SOC-EHL extend beyond a defined threshold. Funding Agencies None

Stones extraction is challenging even for small stones since many factors need to be considered: anatomy of the bile ducts, stone size and number, choice of the device (balloon vs. basket), and technical details (handling of the devices, axis, traction).

Contains fulltext : 229384.pdf (Publisher’s version ) (Open Access) Biliary diseases are common, but clinical symptoms are often unspecific and direct access and visualization of the biliopancreatic system for diagnostic purpose is difficult. In the last decades endoscopic ultrasound (EUS) has become a primary method in the gastrointestinal tract. It significantly changed the role of endoscopy in diagnostic imaging in the gastrointestinal tract and adjacent organs. EUS has become an effective diagnostic tool in biliary stone disease as well as in the diagnosis of indeterminate biliary strictures. Furthermore, an EUS-directed transmural approach emerged as a safe and effective alternative to ERCP in patients requiring biliary drainage, in particular as a backup method if standard ERCP-approach fails. Development of new techniques, specific accessories and stents during the last decade led to an enormous step forward in terms of efficacy and safety of an EUS-directed approach. In the current article technical and clinical aspects of EUS-guided diagnostic and therapeutic approaches in different clinical indications will be discussed together with a review of the available data.

Background Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self‐reported institutional adherence to the Tokyo guidelines (TG18) and ‘real‐world’ contemporary practice across Europe. Methods A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites. Results Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self‐reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60‐day follow‐up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery ‘on call’ service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P, The Tokyo Guidelines 2018 (TG18) describe expert consensus for best practice in the management of complex acute biliary calculous disease. Self‐reported adherence (and limitations to this) were compared with ‘real‐world’ patient‐level data from a prospective observational study, the ESTES snapshot audit. Recognition of TG18 was high, but adherence to guidance on both index admission cholecystectomy and microbiological culture‐guided antibiotic therapy was poor. Low self‐reported and actual adherence to guidelines

Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic technique into a therapeutic-centered modality for managing biliary disorders. Despite its many therapeutic benefits, radiation exposure from ERCP fluoroscopy is of concern and should be minimized as much as possible. Although the use of personal equipment offers significant protection against radiation, attention has been given to the development of non-radiation-based ERCP techniques. To this end, digital cholangioscopy and endoscopic ultrasound-assisted ERCP have emerged as alternatives to standard ERCP. Both techniques have sufficient feasibility and potential diagnostic accuracy to eliminate the need for fluoroscopy. Here we discuss the advances in non-radiation ERCP techniques and their role in the management of biliary stones.

Advanced ERCP techniques (AETs) for difficult biliary stones include peroral cholangioscopy (POC) with electrohydraulic/laser lithotripsy (EHL/LL), endoscopic papillary large balloon dilation (EPLBD) and mechanical lithotripsy (ML). We assess the efficacy of AETs.A retrospective query for AETs.Complete duct clearance. Secondary outcome: Complete duct clearance by technique. Statistical Analysis version 9.3 (SAS Inc., Cary, NC).From 1/00 to 10/12, 349 patients were identified of which 222 (80% had prior ERCPs) had AETs. 211 with sufficient follow-up underwent 295 ERCPs; 280 of which were AET's. Index AETs: POC with EHL/LL (n = 46/211, 22%), ML (n = 84/211, 40%), EPLBD with mean balloon size of 11.5 ± 1.7 mm (n = 39/211, 18%) and combination AETs (n = 42/211, 20%). Stone characteristics: 76% had ≥1 stone, 81% extrahepatic and 32% had strictures. Number of stones (mean 2.5 and range 1-20) did not differ among groups. EPLBD had higher percentage (95%) of extrahepatic stones (p = .0003). The 'Combination' and 'POC' groups had larger stones (mean 17.7 mm ±6.4 and 16.8 mm ±6.1, respectively; p .001). Complete clearance: 209/211 (99%) at index AET 167/211 (79%) or after mean of 2.5 ± 0.7 AETs in 42/211 (20%). Partial clearance: 2/211 (1%). Clearance at index AETs was higher with EPLBD (90%, p = .014). Adverse Events: 7/280 (2.5%).AETs achieved clearance in 99%. EPLBD had higher clearance at index AET likely owing to higher extrahepatic stones. Larger stones, but not number, were associated with increased combination AETs and total ERCPs.

This study reports the clinical and biological signs, as well as the morphological aspect and the chemical composition of the calculus during the biliary stones. The study population consisted of 31 patients with an average age of 49 years (30 women and one man) with biliary lithiasis and who had cholecystectomy. Hepatic colic and epigastralgia were the most evocative clinical signs. The calculus were pigmentary (n=6), cholesterolic and mostly single (n=18), and mixed (n=6) and one infectious multiple lithiasis. Cholesterol was found in 22 calculi (70.96%). We have found a significant increase in liver enzymes and total bilirubin, which is more pronounced in pigmentary lithiasis. Our results showed that most gallstones were composed of cholesterol. These results indicate the influence of diet and chronic hemolysis in calculus formation. More investigation should allow knowing the nutritional and environmental factors influencing gallstones formation in Tunisia, in order to prevent this disease.

This case report describes a young female patient with a history of surgery to treat choledochal cyst since childhood who was admitted to our hospital with cholangitis. An imaging examination revealed giant stones that almost completely filled the intrahepatic biliary tract. The patient underwent percutaneous transhepatic lithotripsy using a holmium laser. After the lithotripsy, cholangiography showed no residual stones. The patient displayed clinical improvement and was discharged after 14 days in the hospital. This case serves as a reminder of gallstone complications that can occur subsequent to choledochal cyst surgery with biliary-enteric anastomosis and emphasizes many outstanding advantages of percutaneous transhepatic lithotripsy compared with classical surgery.

Background/study aims Laser lithotripsy can effectively fragment complicated biliary stones, but current cholangioscopes are limited by fragility, restricted mobility or moderate visual resolution. The efficacy and safety of a new digital single-operator peroral cholangioscope to guide laser lithotripsy were evaluated. Patients and methods In this prospective single-center series, consecutive patients with complicated biliary stones, defined as impacted stones > 1.5 cm in size and wider than the more distal common bile duct, or stones that failed extraction by basket mechanical lithotripsy, underwent ERCP and SpyGlass DS peroral cholangioscope (Boston Scientific, Marlborough, United States)-guided laser lithotripsy. Stone clearance rate and incidence of adverse events were determined. Results Seventeen patients (10 men, 7 women; median age 76 years) with a median biliary stone size of 2 cm underwent predominantly holmium:yttrium aluminum garnet laser lithotripsy, achieving a 94 % stone clearance rate over 1 median procedure. Lithotripsy was performed in 8 of 17 patients due to an impacted biliary stone. The remaining patients underwent lithotripsy due to prior failure of the basket mechanical lithotripter to capture or crush their stones. Post lithotripsy, 2 patients developed cholangitis and 1 patient with underlying COPD developed respiratory distress, all resolved with conservative management. There were no hemobilia, perforations, pancreatitis nor any deaths. Conclusion SpyGlass DS peroral cholangioscopy-guided laser lithotripsy is an efficient and safe modality for management of complicated biliary stones.

Highlight Kawakami and colleagues reported a case of complete clearance of intrahepatic bile duct stones via endoscopic ultrasonography-guided hepaticogastrostomy (EUS-HGS) confirmed under direct antegrade peroral transluminal video cholangioscopy (POTVCS). EUS-guided extraction is applicable in selected patients after failed transpapillary extraction. Moreover, POTVCS via the EUS-HGS route is effective for confirming complete clearance.

Background The optimal methods for patients with difficult biliary stones remain under debate. The aim of this study was to evaluate the role of frequency-doubled double-pulse neodymium YAG (FREDDY) laser lithotripsy for removing difficult biliary stones during laparoscopic common bile duct exploration (LCBDE). Methods Between March 2013 and January 2015, 42 consecutive patients with difficult biliary stones who underwent LCBDE with FREDDY laser lithotripsy were included in this study. The clinical data of all patients were retrospectively collected and analysed. Results Bile ducts were completely cleared in all patients. The complications related to laser lithotripsy were not noted. A total of 38 patients (90.5%) underwent primary closure of common bile duct, and T-tube drainage was applied to four patients (9.5%). No bile duct injury, bleeding and perforation were observed. There were no post-operative surgery-related deaths. Bile leakage occurred in four patients (9.5%) with primary closure procedure, and all of them were managed successfully with conservative therapy. The median follow-up period was 42.8 months, with no evidence of bile duct stricture and stone recurrence in all patients. Conclusions The LCBDE combined with FREDDY laser lithotripsy appear to be effective and safe for the treatment of difficult biliary stones.

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

International audience; The proportion of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with a periampullary duodenal diverticulum ranges in the literature from 9 % to 32 % [1]. The prevalence of periampullary diverticula increases with age, and they are associated with a higher risk of choledocholithiasis [2]. In a few series, they have been identified as a risk factor for difficulty in and failure of biliary catheterization [3]. Several techniques have been proposed to facilitate cannulation, such as clips, or in one case forceps [4] [5]. [Video 1] shows three patients who benefited from our technique involving double instrumentation in one channel for the treatment of biliary obstruction with peridiverticular papillae.Among 7151 ERCPs performed between 2008 and 2017, a duodenal diverticulum was found in 346 patients (5 %). Among these, nine patients with a non-visible or non-reachable orifice benefited from the previously described technique for cannulation. The objective was to reverse the papilla’s orifice to stabilize it in front of the sphincterotome.The procedures were performed with a duodenoscope (Olympus TJF 160; operating channel 4.2 mm). The devices used were a sphincterotome (Cotton Cannulatome II; Cook Medical, USA) loaded with a 0.035-inch guidewire (JagWire; Boston Scientific, USA) and pediatric biopsy forceps (Captura 1.8 mm; Cook Medical), which were simultaneously introduced into the operating channel. The papilla was grasped at its base and pulled back towards the tip of the sphincterotome, which was advanced to catheterize the bile duct with the wire ([Fig. 1]). The procedure was successful in less than 10 minutes without the need for a precut in all of the patients. The findings were biliary stones in six patients, undetermined stricture in two patients, and pancreatic cancer in one patient. No adverse events occurred.In conclusion, this approach using pediatric forceps simultaneously introduced with the sphincterotome to fix the papilla and facilitate cannulation is very useful, safe, and effective in patients with a periampullary diverticulum and difficult access to the orifice, helping to avoid the need for a challenging precut.

Background and Aims Certain pancreaticobiliary conditions remain challenging to treat using standard endoscopic techniques. Examples include difficult-to-remove gallstones and foreign objects in the bile ducts. Two tools designed for these purposes are the SpyGlass retrieval basket and the SpyGlass retrieval snare, which are passed through the cholangioscope channel for use under direct visualization. We present 3 cases in which these tools were used successfully. Methods Three cases using the SpyGlass retrieval basket and retrieval snare were reviewed for efficacy. Results Patient 1 had hepatitis C cirrhosis and underwent liver transplantation with T tube placement at the site of biliary anastomosis. Image-guided T tube removal by interventional radiology was unsuccessful. Endoscopic removal with the SpyGlass retrieval snare was completed. Patient 2 presented with cholangitis from an impacted common bile duct stone. Fragmentation with electrohydraulic lithotripsy was performed, and the fragments were removed with the SpyGlass retrieval basket. Patient 3 presented for removal of a migrated biliary stent. The stent was placed a year prior during an ERCP for treatment of choledocholithiasis. Initial removal attempt at an area hospital failed, so the patient was referred to our center, where the Spyglass retrieval snare was used to remove the biliary stent. Conclusions This case series demonstrates initial successes treating biliary pathologic conditions with the SpyGlass retrieval basket and retrieval snare, 2 tools designed for use under direct visualization with the cholangioscope.

The present images refer to a 54-year-old patient with cholangitis due to biliary stones. He underwent distal oesophagectomy and total gastrectomy with Roux-en-Y reconstruction for a tumour of oesophageal-gastric junction 5 years before. An endoscopic retrograde cholangiopancreatography was