Search

Background/aims: Treatment options for difficult bile duct stones are limited. Direct peroral cholangioscopy (POC)-guided lithotripsy may be an option. A newly developed multibending (MB) ultraslim endoscope has several structural features optimized for direct POC. We evaluated the utility of direct POC using an MB ultraslim endoscope for lithotripsy in patients with difficult bile duct stones., Methods: Twenty patients with difficult bile duct stones, in whom stone removal using conventional endoscopic methods, including mechanical lithotripsy, had failed were enrolled from March 2018 to August 2019. Direct POC-guided lithotripsy was performed by electrohydraulic lithotripsy or laser lithotripsy. The primary outcome was complete ductal clearance, defined as the retrieval of all bile duct stones after lithotripsy confirmed by balloon-occluded cholangiography and/or direct POC., Results: The technical success rate of direct POC was 100% (20/20), and the free-hand insertion rate was 95% (19/20). Direct POC-guided lithotripsy, attempted by electrohydraulic lithotripsy in nine patients (45%) and laser lithotripsy in 11 patients (55%), was successful in 95% (19/20) of the patients. Complete ductal clearance after direct POC-guided lithotripsy was achieved in 95% (19/20) of patients. Patients required a median of 2 (range, 1-3) endoscopic retrograde cholangiopancreatography sessions for complete stone removal. Adverse event was observed in one patient (5%) with hemobilia and was treated conservatively., Conclusions: Direct POC using an MB ultraslim endoscope was safe and effective for lithotripsy in patients with difficult bile duct stones.

Background and Aim: The detection of residual or fragmented common bile duct (CBD) stones after lithotripsy can be improved by the high-resolution imaging quality of digital, single-operator cholangioscopy (SOC). However, therapeutic interventions for the removal of residual CBD stones are limited by the lack of appropriate tools. We retrospectively evaluated the role of SOC and the newly developed Dormia basket for the evaluation and removal of stones remaining after lithotripsy., Methods: Thirty-four patients who had undergone lithotripsy for retained CBD stones with no evidence of filling defects in occluded balloon cholangiography from March 2017 to October 2018 were included in the study. After balloon cholangiography, the bile duct was evaluated by SOC for complete evacuation of the stones. The detected residual CBD stones were directly retrieved by inserting the newly developed Dormia basket into the working channel of the SOC. The incidence of residual stones detected by SOC and the success rate of residual stone retrieval by SOC were investigated., Results: Digital SOC was successfully performed in all patients. Of these, 11 patients (32.4%) had residual CBD stones. The residual stones were successfully removed in 10 patients (90.9%) by SOC using the Dormia basket, except in one case of residual stones left in the hepatic duct. There were no adverse events associated with the SOC procedures or direct stone removal., Conclusions: Digital SOC combined with the newly developed Dormia basket was useful for the detection and extraction of residual CBD stones under direct visualization after lithotripsy., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aims: Although cholangiocarcinomas (CCAs) can be diagnosed using several modalities, the detection of early-stage cancers remains unsatisfactory. We explored whether peroral cholangioscopy (POC) could be used to screen for neoplastic bile duct lesions including CCAs in patients with bile duct stones., Methods: Two hundred seven patients who underwent endoscopic removal of bile duct stones were enrolled between August 2010 and July 2018. The primary outcome was the detection rate of intraductal neoplastic biliary lesions by direct POC. Secondary outcomes were the technical success rates of direct POC and POC-guided forceps biopsy sampling (POC-FB), the diagnostic accuracy of the direct POC findings, adverse events, and the number needed to screen to detect a neoplastic bile duct lesion., Results: Direct POC was successful in 199 of 207 patients (96.1%). Mild cholangitis developed in 2 patients (1.0%) and was treated conservatively. Of the 199 successfully performed POCs, 31 patients (15.6%) exhibited abnormal intraductal mucosal lesions. The technical success rate of POC-FB was 90.3% (28/31 patients). The pathologic diagnoses after POC-FB were CCAs (n = 4), intraductal papillary neoplasms of the bile duct (IPN-B) (n = 2), an adenoma with dysplasia (n = 1), and benign lesions (n = 21). Direct POC correctly distinguished non-neoplastic from neoplastic bile duct lesions in 91.6% of patients. Curative surgical resection was performed for the 5 patients with CCAs or IPN-B. The number needed to screen to detect a neoplastic bile duct lesion was 29.6., Conclusions: Direct POC using a dedicated, ultraslim upper endoscope usefully screens for neoplastic bile duct lesions including CCAs in selected patients with bile duct stones., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background: Peroral cholangioscopy (POCS) can be useful for difficult bile duct stone clearance. Large prospective multinational data on POCS-guided lithotripsy for clearing difficult bile duct stones in a single session of endoscopic retrograde cholangiopancreatography (ERCP) are missing., Methods: Patients with difficult bile duct stones (defined as one or more of: largest stone diameter ≥ 15 mm, failed prior attempt at stone clearance, impacted, multiple, hepatic duct location, or located above a stricture) were enrolled at 17 centers in 10 countries. The principal endpoint was stone clearance in a single ERCP procedure using POCS. RESULTS : 156 patients underwent 174 sessions of POCS-guided electrohydraulic or laser lithotripsy. Stone clearance had failed in a previous ERCP using traditional techniques in 124/156 patients (80 %), while 32 /156 patients (21 %) were referred directly to POCS-guided therapy based on preprocedural assessment of the difficulty of stone clearance. In 101/156 patients (65 %), there were impacted stones. POCS-guided stone clearance was achieved in a single POCS procedure in 125 /156 patients (80 %, 95 % confidence interval [CI] 73 % - 86 %), and was significantly more likely for stones ≤ 30 mm compared with > 30 mm (odds ratio 7.9, 95 %CI 2.4 - 26.2; P  = 0.002). Serious adverse events occurred in 3/156 patients (1.9 %, 95 %CI 0.4 % - 5.5 %), and included pancreatitis, perforation due to laser lithotripsy, and cholangitis (n = 1 each), all resolved within 1 week., Conclusion: POCS-guided lithotripsy is highly effective for clearance of difficult bile duct stones in a single procedure and successfully salvages most prior treatment failures. It may also be considered first-line therapy for patients with difficult choledocholithiasis to avoid serial procedures., Competing Interests: Dr. Anthony Teoh is a paid consultant for Boston Scientific Corporation, Taewoong Medical Co., Ltd., Cook Medical, and Micro-Tech Europe. Dr. Benedict Devereaux is a member of the speakers’ bureau of Boston Scientific Corporation. Joyce Peetermans, PhD, Pooja G. Goswamy, and Matthew Rousseau are employees of Boston Scientific Corporation, the sponsor of this registry. Dr. Takao Itoi is a consultant to Boston Scientific Corporation, Olympus Corporation, Fujifilm Corporation, and Gadelius Medical. All other authors disclose no financial or other relationships related to the work described in this manuscript., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background & Aims: It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones., Methods: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct., Results: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001)., Conclusions: In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background/aims: Treatment for cholangitis without common bile duct (CBD) stones has not been established in patients with gallstones. We investigated the usefulness of endoscopic biliary drainage (EBD) without endoscopic sphincterotomy (EST) in patients diagnosed with gallstones and cholangitis without CBD stones by endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS)., Methods: EBD using 5F plastic stents without EST was performed prospectively in patients with gallstones and cholangitis if CBD stones were not diagnosed by ERCP and IDUS. After ERCP, all patients underwent laparoscopic cholecystectomy. The primary outcomes were clinical and technical success. The secondary outcomes were recurrence rate of biliary events and procedure-related adverse events., Results: Among 187 patients with gallstones and cholangitis, 27 patients without CBD stones according to ERCP and IDUS received EBD using 5F plastic stents without EST. The stents were maintained in all patients until laparoscopic cholecystectomy, and recurrence of cholangitis was not observed. After cholecystectomy, the stents were removed spontaneously in 12 patients and endoscopically in 15 patients. Recurrence of CBD stones was not detected during the follow-up period (median, 421 days)., Conclusions: EBD using 5F plastic stents without EST may be safe and effective for the management of cholangitis accompanied by gallstones in patients without CBD stones according to ERCP and IDUS.

Background and Aims: Direct peroral cholangioscopy (POC) by using an ultraslim upper endoscope has been increasingly applied for diagnosis and treatment of diverse biliary diseases. Recently, an intraductal balloon catheter has been used commonly to guide the flexible ultraslim endoscope. However, accessibility into the bile duct remains a limitation of the procedure. The aim of this study was to evaluate the feasibility and success rate of an intraductal balloon-guided direct POC by using an ultraslim endoscope with a newly modified 5F balloon catheter., Methods: In total, 36 patients with biliary obstruction were included prospectively for a direct POC by using an ultraslim endoscope with a newly modified intraductal 5F balloon catheter. The main outcome measure was technical success, defined as successful advancement of the ultraslim endoscope into the obstructed segment of the biliary tree or the bifurcation. Secondary outcomes were mean time for the total procedure, intubation into the common bile duct and advancement up to the target site after intubation of the ultraslim endoscope, technical success rates of diagnostic and therapeutic interventions, and adverse events., Results: The intraductal balloon-guided direct POC using a newly modified 5F balloon catheter was completed successfully in 35 of 36 patients (97.2%). The mean times for total procedure, intubation into the distal common bile duct, and advancement up to the obstructed bile duct segment were 27.3 ± 7.2, 2.2 ± 0.5, and 0.8 ± 0.4 minutes, respectively. In total, 49 interventions were performed in 35 patients, excluding 1 patient in whom we failed to perform direct POC. Technical success of the interventions was achieved with 44 of 49 procedures (89.8%). No adverse events, including cholangitis, were observed., Conclusions: A newly modified 5F balloon catheter seemed to facilitate performing intraductal balloon-guided direct POC for direct visual examination of the bile duct in patients with biliary obstruction. Continued development of endoscopes and accessories are expected to further improve the performance of direct POC., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Endoscopic biliary sphincterotomy (EBS) results in permanent loss of sphincter function and its long-term complications are unknown. Endoscopic papillary balloon dilation (EPBD) is an alternative procedure that preserves sphincter function, although it is associated with a higher risk of pancreatitis than is EBS. The aim of this study was to evaluate the safety and outcomes of EPBD with limited indications for removal of common bile duct (CBD) stones combined with gallstones in patients younger than 40 years., Methods: Young (age < 40 years) patients who had CBD stones combined with gallstones on imaging studies were enrolled in this study. A total of 132 patients were randomly divided into the EPBD group (n = 62) or the EBS group (n = 70) for extraction of CBD stones. The ballooning size of EPBD ranged from 6 to 10 mm., Results: Complete bile duct clearance was achieved in 98.4 % (61/62) of the EPBD group and 100 % (70/70) of the EBS group. Mechanical lithotripsy was required in 8.1 % (5/62) of the EPBD group and 8.6 % (6/70) of the EBS group. The early complication rates were 8.1 % (5/62) (five pancreatitis) in the EPBD group and 11.4 % (8/70) (five [7.1 %] pancreatitis, two bleeding and one perforation) in the EBS group. The recurrence rates of CBD stones were 1.6 % (1/62) in the EPBD group and 5.7 % (4/70) in the EBS group., Conclusions: EPBD with limited indications was safe and effective as EBS for removal of CBD stones combined with gallstones in young patients who had a longer life expectancy.

Background: Endoscopic management of recurrent bile duct stones after endoscopic sphincterotomy (EST) is effective and safe. However, repeat EST for extension of a previous EST for recurrent bile duct stones may involve substantial risk. The aim of the present study was to evaluate the safety and efficacy of endoscopic papillary large balloon dilation (EPLBD) without repeat EST for recurrent difficult bile duct stones after previous EST., Patients and Methods: From January 2006 to October 2010, a total of 52 patients were enrolled; all had undergone EPLBD (balloon diameter: 12-20 mm) to remove recurrent difficult bile duct stones after previous EST. In all patients, stone removal had failed with conventional methods using a basket and/or balloon. The size of the balloon for EPLBD was selected to fit the diameter of the common bile duct or the largest stone., Results: The median interval between initial EST and stone recurrence was 2.2 years (range 1-10). Median diameters of thelargest stone and balloon were 20.1 mm (range 12-40) and 14.7 mm (range 12-20), respectively. Complete stone removal was achieved in all patients (100%). The median number of endoscopic retrograde cholangiopancreatography sessions needed for complete stone removal was 1.6 (range 1-3). Additional lithotripsy was required in 16 patients (30.7%). No procedure-related complications were documented, with the exception of four cases of asymptomatic hyperamylasemia. The recurrence rate of CBD stones after bile duct clearance was 17.3% (9/52) during the follow-up period (mean 27.0 ± 14.1 months)., Conclusions: EPLBD without repeat EST is effective and relatively safe for the extraction of recurrent difficult bile duct stones after previous EST., (© 2013 The Authors. Digestive Endoscopy © 2013 Japan Gastroenterological Endoscopy Society.)

Background: Lack of established guidelines for endoscopic papillary large balloon dilation (EPLBD) may be a reason for aversion of its use in removal of large common bile duct (CBD) stones., Aims: We sought to identify factors predictive of adverse events (AEs) following EPLBD., Methods: This multicenter retrospective study investigated 946 consecutive patients who underwent attempted removal of CBD stones ≥10 mm in size using EPLBD (balloon size 12-20 mm) with or without endoscopic sphincterotomy (EST) at 12 academic medical centers in Korea and Japan., Results: Ninety-five (10.0 %) patients exhibited AEs including bleeding in 56, pancreatitis in 24, perforation in nine, and cholangitis in six; 90 (94.7 %) of these were classified as mild or moderate in severity. There were four deaths, three as a result of perforation and one due to delayed massive bleeding. Causative factors identified in fatal cases were full-EST and continued balloon inflation despite a persistent waist seen fluoroscopically. Multivariate analyses showed that cirrhosis (OR 8.03, p = 0.003), length of EST (full-EST: OR 6.22, p < 0.001) and stone size (≥16 mm: OR 4.00, p < 0.001) were associated with increased bleeding, and distal CBD stricture (OR 17.08, p < 0.001) was an independent predictor for perforation. On the other hand, balloon size was associated with deceased pancreatitis (≥14 mm: OR 0.27, p = 0.015)., Conclusions: EPLBD appears to be a safe and effective therapeutic approach for retrieval of large stones in patients without distal CBD strictures and when performed without full-EST.

Background: Very few clinical trials have reported on the success rate of frequency-doubled double-pulse yttrium aluminum garnet (YAG) laser (FREDDY) technology for removal of difficult bile duct stones., Objective: Our purpose was to evaluate the role of FREDDY technology for removing difficult bile duct stones., Design: Nonrandomized, retrospective study., Setting: Academic medical center., Patients: Fifty-two patients with difficult bile duct stones were treated via the transpapillary route by using a FREDDY system. The inclusion criteria were impacted or large common bile duct stones (>15 mm, mean 23.5 mm, range 15-35 mm, mean number of stones 1.7, range 1-4). Laser lithotripsy was performed with cholangioscopy guidance in 7 patients and fluoroscopic guidance alone in 45 patients., Main Outcome Measurements: The success rate of complete stone removal and the complication rate related to the procedure., Results: Of the 52 patients treated via the transpapillary route, complete stone removal was achieved in 48 patients (92.3%). The complete removal of stones required a mean of 1.4 (range 1-2) endoscopic sessions. The rate of complications related to laser lithotripsy was 23.0% (acute pancreatitis, 3 cases; transient hemobilia, 8 cases; acute cholangitis, 1 case)., Limitations: Nonrandomized, retrospective design., Conclusion: Laser lithotripsy by using the FREDDY system seems safe and effective and allows "blind" fragmentation of bile duct stones under fluoroscopic guidance only.

Background/aims: Cholecystoscopic lithotripsy can be an alternative procedure for the treatment of impacted cystic duct stones in patients who are high risk for surgery. Conventional methods, including electrohydraulic lithotripsy (EHL), occasionally fail due to the inability to access or capture the impacted stones in the narrow, spirally long cystic duct. Using extracorporeal shock wave lithotripsy (ESWL) may be more effective to disintegrate cystic duct stones. The aim of the study is to evaluate the role of ESWL in the endoscopic treatment of impacted cystic duct stones in patients with high operative risk., Methodology: Eleven patients with impacted cystic duct stones who were at high risk for surgery were included in this study. All of them had had a failed initial attempt of percutaneous transhepatic cholecystoscopic lithotripsy (PTCCS-L) followed by percutaneous transhepatic cholecystostomy. Patients underwent ESWL to disintegrate cystic duct stones with endoscopic removal of fragmented stones., Results: Complete removal of cystic duct stones was achieved in 9 of 11 patients (81.8%). One of the 9 patients (11.1%) was treated solely with ESWL, but the other 8 patients (88.9%) required cholecystoscopic removal of residual fragmented stones after ESWL. Fragmented stones passing through the cystic duct impacted in ampullary region in 3 patients after ESWL. Two patients required transpapillary removal of stones., Conclusions: Endoscopic stone removal after ESWL for impacted cystic duct stones is a difficult and time-consuming procedure. But, it seems to be a relatively safe alternative to surgery in patients with high surgical risk.

Background: Electrohydraulic lithotripsy is a highly effective method for fragmenting biliary stones, but direct visual control is required. The efficacy and the safety of electrohydraulic lithotripsy without cholangioscopy by using a balloon catheter were evaluated in patients with bile-duct stones that could not be extracted by using standard techniques., Methods: Nineteen patients with extrahepatic bile-duct stones that could not be extracted by using conventional endoscopic methods, e.g., mechanical lithotripsy, were selected to undergo electrohydraulic lithotripsy without peroral cholangioscopy. An electrohydraulic lithotripsy probe with a 3.0 F radio-opaque tip was inserted through a balloon catheter. Electrohydraulic lithotripsy was performed under fluoroscopy until the fragmented stone could be captured in a large basket for mechanical lithotripsy. Endoscopic removal of the fragments was attempted during the electrohydraulic lithotripsy session., Results: Stones were successfully fragmented in 17 of 19 patients. In 16 patients (84.2%), the bile duct was cleared of all stones. A mean of 1.8 endoscopic sessions was required for complete removal. Additional mechanical lithotripsy was performed in 9 (56.2%) of the 16 patients. Minor complications were noted in 4 patients (2 hemobilia, 1 pancreatitis, 1 cholangitis). There was no 30-day mortality., Conclusions: For a selected group of patients with bile-duct stones not extractable by using standard techniques, fluoroscopically controlled electrohydraulic lithotripsy with a balloon catheter seems to be an effective method of fragmentation.

Several cases of recurrent stone formation caused by a surgical material as a nidus have been reported. Recently, we experienced one case in which a migrated metal stent might have been served as a nidus for common duct stone formation. The diagnosis was confirmed by ERCP, the stone was successfully removed with endoscopic therapy. Six years ago, she had undergone a lithotripsy using a percutaneous cholangioscopy (PTCS) because of intrahepatic bile duct stones. Six years later, she developed abdominal pain in the right upper quadrant. ERCP revealed the dilated extrahepatic bile duct and left intrahepatic bile duct and the presence of a large elongated freely mobile filling defect suggestive of common bile duct stone containing metal mesh in the distal common bile duct. The removed stone with endoscopic sphincterotomy was soft and dark brown in color with metal stent.

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) has rendered endoscopic gallbladder assessment through a stent possible, but an appropriate endoscope is required. We assessed the feasibility of peroral cholecystoscopy (POCC) using a multibending ultraslim endoscope passed through a LAMS after EUS-GBD.Methods: 14 patients with a LAMS for EUS-GBD who consecutively underwent POCC were included. POCC was performed using a multibending endoscope inserted through the LAMS. The primary outcome was the technical success rate, defined as complete endoscopic examination of the gallbladder from the orifice of the cystic duct to the fundus. The types of intervention and adverse events were recorded.Results: 17 POCCs were performed in 14 patients. Of the 17 POCCs, 15 (88.2 %) were technically successful. Narrow-band imaging endoscopy was performed in 12 procedures (70.6 %), and cholecystoscopy-guided target biopsies were obtained in six. Gallstone extraction was performed in two patients. After POCC, all LAMSs remained stable and no adverse events were observed.Conclusions: POCC using a multibending ultraslim endoscope can be effectively and safely performed through a LAMS after EUS-GBD. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic management of a benign biliary stricture (BBS) on the hilum is complicated and challenging. Although the placement of a fully covered self‐expandable metal stent (FCSEMS) is possible to increase effectiveness, stent migration and stent‐induced adverse events are problematic. We aimed to evaluate the usefulness of a modified short FCSEMS with a long lasso in patients with a difficult perihilar BBS. Methods: Patients with perihilar BBS within 2 cm from the hilar confluence that failed initially with plastic stents were enrolled. A modified short FCSEMS was deployed and then removed 5–6 months later. The primary outcome was clinical success. Other technical success, adverse events, endoscopic success of stent removal, and recurrence of stricture during the follow‐up period were measured. Results: Endoscopic intraductal placement was technically successful in all patients (n = 19). Combined contralateral plastic stent placement was performed in 13 patients (68.4%). The median duration of stent placement was 163 days (range, 138–196 days). Endoscopic stent removal was successful in all patients except one spontaneous distal migration. Stricture resolution without de novo focal stricture occurrence was 100%. Endoscopic stone removal after stricture improvement was successful in all 13 patients with bile duct stones above the stricture. During a follow‐up period (median 635 days) after stent removal, only one recurrence developed. Conclusions: Temporary placement of a modified intraductal short FCSEMS with or without a contralateral plastic stent improved perihilar BBS in patients that primarily failed by plastic stents. Combined biliary stones were also successfully removed after stricture resolution. [ABSTRACT FROM AUTHOR]

Background and Aim Identifying a bile duct ( BD) stone in patients with acute biliary pancreatitis ( ABP) is important for the management and prevention of recurrent attack of pancreatitis. However, small BD stones may not be detected on endoscopic retrograde cholangiopancreatography ( ERCP). The aim of this study was to prospectively evaluate the usefulness of intraductal ultrasonography ( IDUS) in patients suspected to have ABP but with no evidence of choledocholithiasis on ERCP. Methods A total 92 patients suspected with ABP without evidence of BD stones on imaging studies including ERCP were enrolled. Wire-guided IDUS was performed during ERCP in all patients. Stones or sludge detected by IDUS were confirmed after endoscopic sphincterotomy ( EST) and extraction. If IDUS finding was negative, then we swept the BD with a balloon catheter and/or basket without EST. After endoscopic management, comparison between IDUS and endoscopic finding was carried out to determine the diagnostic accuracy of IDUS. Results Among the 92 patients, IDUS revealed BD stones in 33 (35.9%). All 33 patients' stones were confirmed by endoscopic visualization after EST and BD exploration. During the mean follow up of 24 months, recurrent pancreatitis did not occur in 90 of 92 patients (97.9%) with ABP after endoscopic treatment according to the IDUS findings. Conclusions IDUS improves diagnostic accuracy for the detection of clinically occult BD stones in patients suspicious ABP. IDUS-guided endoscopic management for patients with ABP can avoid unnecessary EST and help prevent recurrent pancreatitis. [ABSTRACT FROM AUTHOR]

OBJECTIVES:For frail, elderly patients with large impacted common bile duct (CBD) stones, long-term treatment with biliary stenting provides palliation. Biliary stenting with choleretic agents such as ursodeoxycholic acid (UDCA) and terpene preparations may promote CBD stone size reduction. We studied the effectiveness of biliary stenting combined with UDCA and a terpene preparation as a medical treatment for difficult-to-remove CBD stones in patients older than 65 years in this multicenter, prospective study.METHODS:A total of 28 elderly patients with CBD stones refractory to conventional endoscopic removal, including mechanical lithotripsy, underwent endoscopic placement of a straight 10-F plastic biliary stent. Each patient was administered 600 mg of UDCA and 300 mg of a terpene preparation daily for a mean of 6 months. After 6 months of medication following the initial endoscopic retrograde cholangiopancreatography (ERCP), a second ERCP was performed and endoscopic stone removal was again attempted. Differences in stone size and CBD diameter before and after biliary stenting and medication were compared. The complete stone removal rate after treatment was obtained.RESULTS:The mean size (transverse × longitudinal diameter) of the CBD stones was initially 21.6 × 29.5 mm, and it decreased significantly to 12.2 × 20.1 mm at the second ERCP (P<0.01). The mean CBD diameter measured initially at the cystic duct insertion level was 23.2 mm, and it decreased significantly to 19.5 mm at the second ERCP (P<0.01). After biliary stenting with medication, endoscopic stone removal was successful in 26 of 28 patients (92.8%), with a mean of 1.7 subsequent ERCP sessions.CONCLUSIONS:Endoscopic biliary stenting with a period of combined UDCA and terpene preparation administration seems to be a safe and effective method for retained CBD stones in elderly patients. A prospective study with randomization and a control group is required to confirm these results. [ABSTRACT FROM AUTHOR]