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The authors analyze what should be the best approach to treat patients who had concomitant gallstones and common bile duct stones (CBDS). Laparoscopic common bile duct exploration (LCBDE) appears to be an atractive way to cure all kind of biliary stones in a single procedure. However, when scientific literature is reviewed most patients continue to need from ERCP for CBDS removal. ERCP can be performed before, after or during the same LC procedure. Patients with LCBDE had less pancreatitis rate because the Papilla of Vater is not manipulated but more bile leaks. Large CBDS continue to need, in general, from ERCP techniques.

Balloon sphincteroplasty is a well-known procedure for the treatment of biliary stones. Scoring balloons are characterized by rigid tangential elements that provide focal force, achieving a greater pressure than normal balloons. We report the first (to our knowledge) use of a scoring balloon to perform sphincteroplasty in 4 cases of elderly people presenting with symptomatic choledocholithiasis. In all cases we achieved complete common bile duct clearing with good symptom relief. No procedural complications were observed.

Background: Pancreaticobiliary diseases and choledocholithiasis are common in elderly patients. Endoscopic treatment of biliary stones represents a well-established mini-invasive technique. However, limited data are available regarding the treatment of 'difficult' biliary stones, especially in the elderly population. The aim of our study is to evaluate the efficacy and safety of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in patients ≥85 years of age with complex biliary stones.Materials and Methods: From January 2015 to January 2017, data from ERCP procedures performed for complex biliary stones were retrospectively collected. The patients were divided into two groups based on their age: Group A - aged 85 years or older (n = 110) and Group B - aged 65 years or younger (n = 62). Demographic data, success, complications and recurrence rates for both groups were reported.Results: Chronic comorbidities (86.3% vs. 24.2%; P < 0.001) and use of antithrombotic drugs (48.2% vs. 19.3%; P < 0.001) were more frequent in the elderly. The technical success rate (95.4% vs. 96.7%; P > 0.6) and complication rate (8.2% vs. 13%; P > 0.2) were not statistically different among the two groups. Periampullary diverticula (PAD) were observed more frequently in Group A (38.1% vs. 17.7%; P < 0.006). More patients from Group B underwent cholecystectomy during the same admission (8.2% vs. 42.3%; P < 0.001). The recurrence rate was not different among the groups (7.6% vs. 5%; P > 0.5). PAD was identified as the risk factor for recurrence (P < 0.02).Conclusion: ERCP in the elderly was found to be a safe procedure, carrying a high degree of success for the treatment of difficult biliary stones.

Biliary complications develop in 10–40 % of patients following liver transplantation. Biliary strictures, leaks, and stone are the most common type of complications. In this study, we focused on the endoscopic treatment of biliary stones. Among 142 patients with liver transplantation [22 deceased donor related (DDLT), 120 live donor related liver transplantation (LDLT)] who underwent endoscopic retrograde cholangiopancreatography (ERCP) between December 2013 and September 2015, 33 (11 with DDLT, 28 male, mean age 45 ± 13 years) had one or more biliary stones. ERCP was performed through papilla in all of the patients other than a patient with hepaticojejunostomy. Biliary stones were extracted in all 6 patients without anastomosis stricture (AS), 3 of 6 (50 %) patients with DDLT and AS, in 13 of 16 (81.5 %) patients with LDLT and AS, and in 3 of 5 (60 %) patients with non-anastomosis stricture (NAS). The total number of sessions required for the extraction of stones was less in patients with biliary stones without AS [1.5 (1–2)] compared to those with AS and DDLT [2 (1–6)] or LDLT [3 (1–5)]. Patients with NAS (n = 5) required a greater number of sessions [7 (1–10)]. Stone extraction is difficult in patients with NAS and requires a greater number of ERCP sessions. The treatment of biliary stones proximal to an AS in patients with DDLT or LRLT is possible in most cases.

The role of the interventional radiologist continues to expand in the treatment of biliary disease. Percutaneous transhepatic cholangioscopy (PTCS) provides direct visualization of the biliary system for diagnostic and therapeutic interventions, especially in cases where anatomical considerations prohibit a peroral approach. Visual inspection and endoscopically guided biopsy allow differentiation between benign and malignant lesions, as well as accurate assessment of the tumor extent for surgical planning. Studies have demonstrated greater than 95% accuracy with PTCS in diagnosing biliary malignancies. Cholangioscopy is also used to treat obstructive stones in the biliary system, which may require laser lithotripsy. PTCS-guided removal of biliary stones is highly successful, with complete stone removal from the bile ducts occurring in approximately 90% of cases. Overall, PTCS is a safe and effective procedure, with severe complications occurring in less than 8% of patients. The purpose of this review is to familiarize its reader with common indications for PTCS, techniques for procedural success, expected outcomes, and management of potential complications.

Periampullary duodenal diverticula are common and are usually asymptomatic. However, complications like biliary or pancreatic obstruction, duodenal obstruction, perforation, or hemorrhage can occur occasionally. Obstructive jaundice is usually due to biliary stones and periampullary tumors. Rarely, duodenal diverticula may present with obstructive jaundice in the absence of cholelithiasis or other detectable obstacle. This condition is called Lemmel's syndrome. There are only few case reports of this rare condition. We report a case of 78-year-old man presenting with painless obstructive jaundice due to Lemmel's syndrome which was diagnosed on endoscopic ultrasonography.

Oriental cholangiohepatitis (OCH) is a disease characterized by intrabiliary pigment stone formation, resulting in recurrent bouts of cholangitis. OCH is found mostly in Southeast Asia but it is occasionally recognized in Western societies. OCH etiology is largely unknown. We report our experience with a patient who presented with acute cholecystitis. Following laparoscopic cholecystectomy, she developed acute cholangitis due to multiple biliary tree stones. She underwent ERCP to clear the stones from common bile duct. For the intrahepatic stones, she underwent novel hybrid percutaneous endoscopic technique. The procedure resulted in complete clearance of biliary tree stones and resolution of her symptoms. The aim of this case is to increase awareness of this disease when patients from endemic areas present with biliary stones.

Background Recently, the introduction of the novel digital SpyGlass™ DS Direct Visualization system (Boston Scientific Corp., Natick, MA, USA) has signaled the transition into the era of digital single-operator cholangioscopy (D-SOC). We sought to compare the clinical utility between fiberoptic single-operator cholangioscopy (F-SOC) and D-SOC in a tertiary-care referral center in Greece. Methods This was a retrospective analysis of a prospective database of single-operator cholangioscopy (SOC) procedures performed over an 8-year period (2009-2017) at a single tertiary-care referral center. The study population consisted of consecutive adults referred for cholangioscopy for a variety of clinical indications, including biliary strictures, difficult biliary stones and migrated or occluded pancreatic or biliary stents. Results A total of 2763 endoscopic retrograde cholangiopancreatography procedures were performed during the study period. Overall, SOC was performed in 68 (2.46%) procedures (F-SOC=39, D-SOC=29), showing a significant increase in the utilization of cholangioscopy during the D-SOC (29/599; 4.84%) compared with the F-SOC (39/2124; 1.83%) period (P=0.0001). The overall technical success of diagnostic SOC was 69.1% (38/55), being marginally higher for D-SOC (83.3%) than for F-SOC (58.1%), although not reaching statistical significance (P=0.07). Conclusions D-SOC was utilized more frequently in our tertiary-care non-academic referral center, demonstrating a favorable safety profile and a trend towards a marginally higher technical success rate for the diagnosis of biliary strictures compared with F-SOC.

Roux-en-Y gastric bypass surgery remains a popular surgical intervention worldwide to treat morbid obesity. It is effective and relatively safe. However, one of the results related to bariatric surgery-induced rapid weight loss is the development of biliary stones. Endoscopic removal of common bile duct stones is challenging in patients with Roux-en-Y gastric bypass reconstruction. The current review highlights the different endoscopic approaches of the biliopancreatic system to perform endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y gastric bypass. A treatment algorithm is provided based on clinical indications.

STRESZCZENIEAnomalie anatomiczne przebiegu zewnątrzwątrobowych dróg żółciowych należą do stosunkowo częstych, występując u ok. 16% pacjentów. Najczęściej zdarza się nietypowy przebieg przewodu pęcherzykowego i jego połączenia z przewodem wątrobowym wspólnym. Anomalie budowy pęcherzyka żółciowego są znacznie rzadsze i nieczęsto opisywane ze względu na ich mniejsze znaczenie kliniczne. W pracy przedstawiono przypadek chorej z dwuczęściowym pęcherzykiem żółciowym, którego część dalsza była wypełniona kamieniami i zmieniona zapalnie, a część bliższa nie zawierała kamieni i była zdrowa. Operacja, choć trudna technicznie ze względu na anomalię anatomiczną i naciek zapalny, przebiegła bez powikłań, a chora wyzdrowiała.

Background and study aims Endoscopic removal of biliary stones has high success rates, ranging between 85 % to 95 %. Nevertheless, some stones may be challenging and different endoscopic methods have evolved. Papillary large balloon dilation after sphincterotomy is a widely used technique with success rates ranging from 68 to 90 % for stones larger than 15 mm. Cholangioscopy allows performing lithotripsy under direct biliary visualization, either by laser or electrohydraulic waves, which have similar success rate (80 % – 90 %). However, there is no study comparing these 2 techniques. Patients and methods From April 2014 to June 2016, 100 patients were enrolled and randomized in 2 groups, using a non-inferiority hypothesis: cholangioscopy + electrohydraulic lithotripsy (group 1) and endoscopic papillary large balloon dilation (group 2). The main outcome was complete stone removal. Adverse events were documented. Mechanical lithotripsy was not performed. Failure cases had a second session with crossover of the methods. Results The mean age was 56 years. 74 (75.5 %) patients were female. The initial overall complete stone removal rate was 74.5 % (77.1 % in group 1 and 72 % in group 2, P > 0.05). After second session the overall success rate achieved 90.1 %. Procedure time was significantly lower in group 2, – 25.2 min (CI95 % – 12.48 to – 37.91). There were no significant differences regarding technical success rate, radiologic exposure and adverse events. Conclusion Single-operator cholangioscopy-guided lithotripsy and papillary large balloon dilation are effective and safe approaches for removing complex biliary stones.

Introduction and Objective: Choledocolithiasis is a significant problem that can lead to severe cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. However, this is not always possible when the patient has surgically altered anatomy or very large stone burden. Urologists can use our skills and technology to assist in these situations. We report our technique and outcomes from our 15 years of experience with percutaneous transhepatic endoscopic biliary lithotripsy. Methods: Patients are selected by our gastroenterology colleagues who approach us for assistance when ERCP is not possible. We utilize a percutaneous transhepatic endoscopic approach in a combined procedure with interventional radiology. Most patients have a transhepatic biliary drain already in place. A wire is then placed through the tube into the biliary system and into the common bile duct. A 14F ureteral access sheath is placed under fluoroscopic guidance into the common bile duct. A flex...

Cholangioscopy was first performed in the 1970s. We now use the term cholangiopancreatoscopy (CP) to reflect the wider application of these miniature reusable dual-operator "mother-daughter" endoscope systems and now fully disposable and digital single-operator optical catheters for evaluating the biliary or pancreatic duct. Cholangioscopy is an established modality for the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Pancreatoscopy is increasingly being performed to treat difficult pancreatic duct stones and may be used to distinguish malignant from benign ductal pathology. This review covers available CP technologies, indications, technique, efficacy, and complications.

Objectives: Clinical evidence regarding radiological–endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological–endoscopic management of intrahepatic difficult bile duct stones. Methods: From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3–7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological–endoscopic approach and reported our technical and clinical outcomes. Results: Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention. Conclusion: After 18 years of experience we demonstrated that our combined radiological–endoscopic approach to ‘difficult bile duct stones‘ may result in both immediate and long-term clearance of stones with a low rate of adverse events.

Purpose: This study was done to assess the role of ultrasound in diagnosis of obstructive jaundice and to identify the most common causes and symptoms. Materials and methods: The study took place in different Khartoum clinical centers and hospitals in the period between Jan 2014 and July 2014. A total of 150 patients with obstructive jaundice were examined using ultrasound machine, 3.5 - 7 MHz probe. Results: The study revealed that 65.33 of the study population with obstructive jaundice were female and 34.67% was male. The most common affected groups were 46 - 65 years old and 25 - 45 years old. The common causes of obstructive jaundice were biliary stones (61.33%) which were common in females and abdominal masses (32.67%) which were common in females, too. Nausea, yellowish discoloration and abdominal pain were the most common symptoms (98%, 97.33% and 96.67% respectively). The causes of obstructive jaundice showed significant difference between males and females (P-value = 0.002). Conclusion: Ultrasound was superior diagnostic tool in detecting and assessing biliary system obstruction, because it was easy, available, accurate and noninvasive. The ageing and gender were considered as risk factors of obstructive jaundice.

Key Clinical Message We present the first description of choledocholithiases in a 10‐year‐old boy with Hemoglobin Evans. Although biliary stones are much less common in children than in adults, epigastric pain in children with known hemolytic status should alert the physician to the possibility of biliary colic.

Computed tomography (CT) is useful for diagnosing biliary stones. However, the presence of stones not detected by conventional CT, such as iso-dense stones with CT numbers similar to those of bile or small stones, is problematic. Although conventional CT provides only 120-kVp images corresponding to CT numbers at approximately 70 keV, dual-layer spectral detector CT uses one X-ray source and dual-layer detectors to collect low- and high-energy data simultaneously; retrospective spectral analysis, including virtual monochromatic images with photon energy levels of 40–200 keV, material decomposition images, and spectral curves, can be immediately performed on demand. This technique can immediately discriminate between materials with similar conventional CT numbers. Therefore, prompt and accurate diagnosis of iso-dense stones can be performed. In two out of three of our cases, iso-dense stones were detected in virtual monochromatic images at 40 keV, but in the remaining case a common 4-mm bile duct stone was not detected on 120-kVp and 40-keV images by retrospective spectral analysis. However, this stone was detected by magnetic resonance cholangiopancreatography. Retrospective spectral analysis using dual-layer spectral detector CT was useful for prompt and accurate diagnosis of iso-dense stones, but detection of

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.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.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).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.

Hepatolithiasis is highly prevalent in Asia but rare in Western countries. However, the incidence of hepatolithiasis may be increasing in Western countries due to the increased rate of immigration from areas where hepatolithiasis is prevalent. There are many non-surgical treatments for hepatolithiasis, but surgical management remains the best curative treatment for some cases of hepatolithiasis. Surgical treatments can remove biliary stones and relieve stricture of the bile ducts. This review describes the indications for and the outcomes of surgical treatment of hepatolithiasis, including liver resection and liver transplantation.

Acute calculous cholecystitis (ACC) is the most frequent complication of cholelithiasis and represents one-third of all surgical emergency hospital admissions, many aspects of the disease are still a matter of debate. Knowledge of the current evidence may allow the surgical team to develop practical bedside decision-making strategies, aiming at a less demanding procedure and lower frequency of complications. In this regard, recommendations on the diagnosis supported by specific criteria and severity scores are being implemented, to prioritize patients eligible for urgency surgery. Laparoscopic cholecystectomy is the best treatment for ACC and the procedure should ideally be performed within 72 h. Early surgery is associated with better results in comparison to delayed surgery. In addition, when to suspect associated common bile duct stones and how to treat them when found are still debated. The antimicrobial agents are indicated for high-risk patients and especially in the presence of gallbladder necrosis. The use of broad-spectrum antibiotics and in some cases with antifungal agents is related to better prognosis. Moreover, an emerging strategy of not converting to open, a difficult laparoscopic cholecystectomy and performing a subtotal cholecystectomy is recommended by adept surgical teams. Some authors support the use of percutaneous cholecystostomy as an alternative emergency treatment for acute Cholecystitis for patients with severe comorbidities.

Background The aim of this study was to compare the efficacy and safety of synchronous laparoscopic cholecystectomy with laparo-endoscopic rendez-vous (LRV) technique vs. sequential "delayed" approach with the main goal to compare the conversion rate and postoperative complications. Methods Patients diagnosed as having gallstones and CBD stones or sludge were enrolled in this study. From January 2013 to June 2015, 43 consecutive patients were submitted to the sequential treatment (ERCP prior to laparoscopic cholecystectomy) and the next consecutive 46 patients were submitted to undergo the rendez-vous technique. All endoscopic procedures in both groups were performed by the same endoscopist with the same technique. Data were collected on patient age, gender, latency operation time, duration of surgery, bilio-pancreatic events, hospital stay, mortality, conversion rate and postoperative complications. Results The overall mean age was 58 years-old (25-84 years) with 43 males (48.3%) and 46 females (51.7%). The conversion rate to open surgery was 11.6% in the "sequential group" vs. 2.2% in the LRV group with a P value 0.10. The reasons for conversion included in the first group unclear anatomy (in 2 patients) and severe adhesions (in the remnant 3 patient), and in the second group unclear anatomy (in one patient). No bilio-pancreatic events occurred in the waiting period for LC in the first group. No mortality was recorded in either group. Postoperative complications were seen in 7% of patients in the "sequential group" vs. 2.2% in the rendez-vous group (P value 0.35). Conclusions LRV does not present real advantages in comparison to delayed sequential approach in terms of conversion rate and postoperative complications. However, these results require further elaboration in studies on large numbers of patients undergoing LRV approach.

Since its introduction, cholangioscopy has been used diagnostically and therapeutically. The working channel size has increased, permitting direct visualization for tissue sampling and to guide application of lithotripsy for difficult stones. Cholangioscopy utilizes endoscope and catheter-based systems. The application of slim gastroscopes for direct cholangioscopy provides better image resolution than conventional systems. Cholangioscopy has proven effective in the management of large biliary stones and for the diagnosis and exclusion of biliary tumors. Commercially available cholangioscopes are fiberoptic; those with digital video technology remain in a prototype development phase. This review covers available cholangioscope technologies, indications, technique, efficacy, and complications.

Background/Aims We evaluated the efficacy and cost-effectiveness of endoscopic papillary large balloon dilation (EPLBD) for large common bile duct (CBD) stone removal compared with endoscopic sphincterotomy (EST).

Background and Aim After selective biliary access following precut fistulotomy in difficult biliary cannulations (DBC), there are several methods of completely opening the remaining papillary roof for the removal of biliary stones. We evaluated the efficacy of one-step transfistula balloon dilation following fistulotomy in DBC for the removal of biliary stones. Methods This retrospective multicenter study was performed in four tertiary referral centers. Patients who underwent fistulotomy due to DBC were enrolled. Precut fistulotomy followed by conventional (≤ 10 mm) or large balloon (≥ 12 mm) dilation through the fistulotomy tract was performed to remove biliary stones. The main outcome measures were technical success and transfistula balloon dilation-related complications. Results A total of 154 patients were enrolled. Large balloon and conventional balloon dilation were performed in 57 and 97 patients, respectively. The primary technical success of stone removal was 100% (57/57) for large balloon dilation and 96.9% (94/97) for conventional balloon dilation (P = 0.296). The mean procedure time from biliary access to removal of stones was 29.3 min in large balloon and 22.2 min in conventional balloon dilation (P = 0.042), and the mean numbers of endoscopic retrograde cholangiopancreatography sessions were 1.4 and 1.3, respectively (P = 0.175). Transfistula balloon dilation-related complications were not different between the two groups (10.5% in large balloon dilation vs 16.5% in conventional balloon dilation, P = 0.307). Conclusions One-step transfistula balloon dilation following precut fistulotomy in DBC may be safe and effective for the removal of biliary stones. There were no differences in therapeutic outcomes and complications between large and conventional balloon dilation.

related ductal abnormalities are asymptomatic and do not require any treatment. Those who are symptomatic require treatment in the form of repeated endoscopic interventions or surgery. Choice of therapy depends on various factors, such as type and number of biliary strictures, presence or absence of veins for shunt surgery, and biliary stones. The currently available imaging modalities include abdominal US, CT, MRI, and EUS. These are all suggestive but not diagnostic of the actual biliary pathology in these patients. With the recent

Background Choledocholithiasis presents in 5-10% of the patients with biliary lithiasis. Numerous treatment algorithms have been considered for this disease, however, up to 10% of these therapeutic procedures may fail. Intraoperative choledochoscopy has become a useful tool in the treatment of patients with difficult-to-manage choledocholithiasis. Objectives To determine the usefulness of intraoperative choledochoscopy in the laparoendoscopic treatment of difficult stones that was carried out in our service. Patients and methods A cross-sectional study was conducted. The case records were reviewed of the patients that underwent intraoperative choledochoscopy during biliary tree exploration plus laparoscopic choledochoduodenal anastomosis within the time frame of March 1, 2011 and May 31, 2012, at the Hospital General Dr. Manuel Gea Gonzalez. Transabdominal choledochoscopies were performed with active stone extraction when necessary, followed by peroral choledochoscopies through the recently formed bilioenteric anastomosis. The data were analyzed with descriptive statistics and measures of central tendency. Results The mean age was 71 years, 57% of the patients were women, and the ASA III score predominated. Active extraction of stones with 7 to 35 mm diameters was carried out in 4 of the cases and the absence of stones in the biliary tract was corroborated in all the patients. The mean surgery duration was 18 minutes (range: 4 to 45 min). Conclusions Choledochoscopy is a safe and effective minimally invasive procedure for the definitive treatment of difficult stones.

Background This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. Methods The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. Results All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. Conclusions ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.

Aims: Endoscopic management of indeterminate strictures and complex stones remains a challenge, for which the latest generation single-operator digital cholangioscope (SpyGlass DS) has shown promising results. We aimed to study the clinical impact of single-operator digital cholangioscope at our tertiary academic center. Methods: We retrospectively reviewed all digital cholangioscopies performed from June 2015 to May 2018. Patient characteristics, procedure characteristics, and post-procedural patient outcomes were recorded. Results: A total of 50 patients (26 men, average age 61.4 years) underwent 67 procedures. Indications were biliary stones (21/50, 42%), strictures and primary sclerosing cholangitis surveillance (22/50, 46%), and miscellaneous (7/50, 14%). The average procedure time was 82 ± 29 min (99.5 min for stones and 74.2 min for strictures). Stone clearance was achieved in 19/21 (90.47%) cases, with electrohydraulic lithotripsy employed in 16/21 and repeat cholangioscopy necessary in 9/21. Malignant strictures (10) were differentiated from benign (12) in all cases both in patients with primary sclerosing cholangitis (9) and in those without (13), based on visual cholangioscopic features (sensitivity and specificity 100%), single-operator digital cholangioscope–directed biopsies (sensitivity 60% and specificity 100%), and brush cytology (sensitivity 37.5% and specificity 100%). Complications included one post-sphincterotomy bleeding and one post-procedural cholangitis despite antibiotic prophylaxis, but no procedure-related mortality. Conclusion: Single-operator digital cholangioscope had a high success rate and a low rate of complications for management of indeterminate strictures and difficult biliary stones. Visual cholangioscopic features of biliary strictures had excellent diagnostic accuracy, and targeted biopsies outperformed brush cytology. Early implementation of cholangioscopy for select indications leads to successful patient outcomes and reduces diagnostic delays, cost, and risks of repeat endoscopic retrograde cholangiopancreatographies.

ERCP is the mainstay of therapy for pancreatobiliary diseases in patients with native upper gastrointestinal (UGI) anatomy. However, when UGI anatomy is surgically altered, standard ERCP becomes technically challenging or not possible. In such instances, EUS-guided biliary drainage (EUS-BD) has been increasingly employed by advanced endoscopists as a safe and effective method of access to the biliary tree. In this study, we review the technical aspects and outcomes of EUS-BD in patients with surgical UGI anatomy.

Purpose of the study To report our experience in treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). Patients and Methods Ten symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Six of these patients had previously undergone unsuccessful endoscopic treatment; four patients were declared not suitable for endoscopic procedure. PTBL was performed with a flexible choledochoscopy inserted by way of the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary and an occlusion balloon for the clearance of common bile duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical follow up was performed by the referring physician. Technical success, clinical success and complications were evaluated. Main findings Technical success rate was 100%. The overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6–25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the patients. Conclusions Complicated or large biliary calculi can be treated successfully using PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.