Surgical strategies for challenging common bile duct stones in the endoscopic era: A comprehensive review of current evidence

While endoscopic retrograde cholangiopancreatography(ERCP)remains the primary treatment modality for common bile duct stones(CBDS)or choledocho-lithiasis due to advancements in instruments,surgical intervention,known as common bile duct exploration(CBDE),is still necessary in cases of difficult CBDS,failed endoscopic treatment,or altered anatomy.Recent evidence also supports CBDE in patients requesting single-step cholecystectomy and bile duct stone removal with comparable outcomes.This review elucidates relevant clinical anatomy,selection indications,and outcomes to enhance surgical understanding.The selection between trans-cystic(TC)vs trans-choledochal(TD)approaches is described,along with stone removal techniques and ductal closure.Detailed surgical techniques and strategies for both the TC and TD approaches,including instrument selection,is also provided.Additionally,this review comprehensively addresses operation-specific complications such as bile leakage,stricture,and entrapment,and focuses on preventive measures and treatment strategies.This review aims to optimize the management of CBDS through laparoscopic CBDE,with the goal of improving patient outcomes and minimizing risks.

Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma: A single-center retrospective study in South Korea

BACKGROUND Intrahepatic duct(IHD)stones are among the most important risk factors for cholangiocarcinoma(CCC).Approximately 10%of patients with IHD stones develop CCC;however,there are limited studies regarding the effect of IHD stone removal on CCC development.AIM To investigate the association between IHD stone removal and CCC development.METHODS We retrospectively analyzed 397 patients with IHD stones at a tertiary referral center between January 2011 and December 2020.RESULTS CCC occurred in 36 of the 397 enrolled patients.In univariate analysis,chronic hepatitis B infection(11.1%vs 3.0%,P=0.03),carbohydrate antigen 19-9(CA19-9,176.00 vs 11.96 II/mL,P=0.010),stone located in left or both lobes(86.1%vs 70.1%,P=0.042),focal atrophy(52.8%vs 26.9%,P=0.001),duct stricture(47.2%vs 24.9%,P=0.004),and removal status of IHD stone(33.3%vs 63.2%,P<0.001)were significantly different between IHD stone patients with and without CCC.In the multivariate analysis,CA19-9>upper normal limit,carcinoembryonic antigen>upper normal limit,stones located in the left or both lobes,focal atrophy,and complete removal of IHD stones without recurrence were independent factors influencing CCC development.However,the type of removal method was not associated with CCC risk.CONCLUSION Complete removal of IHD stones without recurrence could reduce CCC risk.

Removal of intrahepatic bile duct stone could reduce the risk of cholangiocarcinoma

Hepatolithiasis(HL)poses a significant risk for cholangiocarcinoma(CCA)development,with reported incidences ranging from 5%-13%.Risk factors include older age,smoking,hepatitis B infection,and prolonged HL duration.Chronic inflammation and mechanical stress on the biliary epithelium contribute to CCA pathogenesis.Hepatectomy reduces CCA risk by removing stones and atrophic liver segments.However,residual stones and incomplete removal increase CCA risk.Kim et al identified carbohydrate antigen 19-9,carcinoembryonic antigen,and stone laterality as CCA risk factors,reaffirming the importance of complete stone removal.Nonetheless,challenges remain in preventing CCA recurrence post-surgery.Longer-term studies are needed to elucidate CCA risk factors further.

Risk factors for recurrence of common bile duct stones after surgical treatment and effect of ursodeoxycholic acid intervention

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an accurate diagnostic method for choledocholithiasis and treatment option for stone removal.Additionally,ursodeoxycholic acid(UDCA)can dissolve cholesterol stones and prevent their development and reappearance by lowering the cholesterol concen-tration in bile.Despite these treatment options,there are still patients who experience stone recurrence.The clinical data of 100 patients with choledochal stones who were hospitalized at the Yixing People’s Hospital and underwent ERCP for successful stone extraction between June 2020 and December 2022 were retrospectively collected.According to the post-ERCP treatment plan,100 patients were classified into UDCA(n=47)and control(n=53)groups.We aimed to assess the clinical efficacy and rate of relapse in the two patient populations.We then collected information(basic demographic data,clinical characteristics,and serum biochemical indicators)and determined the factors contributing to relapse using logistic regression analysis.Our secondary goal was to determine the effects of UDCA on liver function after ERCP.Compared to the control group,the UDCA group demonstrated a higher clinical effectiveness rate of 92.45%vs 78.72%(P<0.05).No significant differences were observed in liver function indices,including total bilirubin,direct bilirubin,gamma-glutamyl transpeptidase,alanine aminotransferase,alkaline phosphatase,and aspartate aminotransferase,between the two groups before treatment.After treatment,all liver function indices were significantly reduced.Comparing the control vs UDCA groups,the UDCA group exhibited significantly lower levels of all indices(55.39±6.53 vs 77.31±8.52,32.10±4.62 vs 45.39±5.69,142.32±14.21 vs 189.63±16.87,112.52±14.25 vs 149.36±15.36,122.61±16.00 vs 171.33±22.09,96.98±10.44 vs 121.35±11.57,respectively,all P<0.05).The stone recurrence rate was lower in the UDCA group(13.21%)in contrast with the control group(44.68%).Periampullary diverticula(OR:6.00,95%CI:1.69-21.30),maximum stone diameter(OR:1.69,95%CI:1.01-2.85),stone quantity>3(OR:4.23,95%CI:1.17-15.26),and positive bile culture(OR:7.61,95%CI:2.07-27.91)were independent factors that influenced the relapse of common bile duct stones after ERCP(P<0.05).Furthermore,postoperative UDCA was identified as a preventive factor(OR:0.07;95%CI:0.08-0.09).CONCLUSION The intervention effect of UDCA after ERCP for common bile duct stones is adequate,providing new research directions and references for the prevention and treatment of stone recurrence.

Clinical efficacy of laparoscopic cholecystectomy combined with endoscopic papillary balloon dilation in treatment of gallbladder stones with common bile duct stones: A retrospective study

BACKGROUND The incidence of cholelithiasis has been on the rise in recent years,but the choice of procedure is controversial.AIM To investigate the efficacy of laparoscopic cholecystectomy(LC)combined with endoscopic papillary balloon dilation(EPBD)in patients with gallbladder stones(GS)with common bile duct stones(CBDS).METHODS The clinical data of 102 patients with GS combined with CBDS were selected for retrospective analysis and divided into either an LC+EPBD group(n=50)or an LC+endoscopic sphincterotomy(EST)group(n=52)according to surgical methods.Surgery-related indexes,postoperative recovery,postoperative complications,and expression levels of inflammatory response indexes were compared between the two groups.RESULTS Total surgical time,stone free rate,rate of conversion to laparotomy,and successful stone extraction rate did not differ significantly between the LC+EPBD group and LC+EST group.Intraoperative hemorrhage,time to ambulation,and length of hospitalization in the LC+EPBD group were lower than those of the LC+EST group(P<0.05).The rate of total complications of the two groups was 9.80%and 17.65%,respectively,and the difference was not statistically significant.No serious complications occurred in either group.At 48 h postoperatively,the expression levels of interleukin-6,tumor necrosis factor-α,high-sensitivity Creactive protein,and procalcitonin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).At 3 d postoperatively,the expression levels of aspartate transaminase,alanine transaminase,and total bilirubin were lower in the LC+EPBD group than in the LC+EST group(P<0.05).CONCLUSION LC combined with EPBD and LC combined with EST are both effective procedures for the treatment of GS with CBDS,in which LC combined with EPBD is beneficial to shorten the patient’s hospitalization time,reduce the magnitude of elevated inflammatory response indexes,and promote postoperative recovery.

Comparison of the clinical effects of dual-modality endoscopy and traditional laparotomy for the treatment of intra-and extrahepatic bile duct stones

BACKGROUND Bile duct stones(BDSs)may cause patients to develop liver cirrhosis or even liver cancer.Currently,the success rate of surgical treatment for intrahepatic and extrahepatic BDSs is not satisfactory,and there is a risk of postoperative complic-ations.AIM To compare the clinical effects of dual-modality endoscopy(duodenoscopy and laparoscopy)with those of traditional laparotomy in the treatment of intra-and extrahepatic BDSs.METHODS Ninety-five patients with intra-and extrahepatic BDSs who sought medical services at Wuhan No.1 Hospital between August 2019 and May 2023 were selected;45 patients in the control group were treated by traditional laparotomy,and 50 patients in the research group were treated by dual-modality endoscopy.The following factors were collected for analysis:curative effects,safety(incision infection,biliary fistula,lung infection,hemobilia),surgical factors[surgery time,intraoperative blood loss(IBL)volume,gastrointestinal function recovery time,and length of hospital stay],serum inflammatory markers[tumor necrosis factor(TNF)-α,interleukin(IL)-6,and IL-8],and oxidative stress[glutathione peroxidase(GSH-Px),superoxide dismutase(SOD),malondialdehyde(MDA),and advanced protein oxidation products(AOPPs)].RESULTS The analysis revealed markedly better efficacy(an obviously higher total effective rate)in the research group than in the control group.In addition,an evidently lower postoperative complication rate,shorter surgical duration,gastrointestinal function recovery time and hospital stay,and lower IBL volume were observed in the research group.Furthermore,the posttreatment serum inflammatory marker(TNF-α,IL-6,and IL-8)levels were significantly lower in the research group than in the control group.Compared with those in the control group,the posttreatment GSH-Px,SOD,MDA and AOPPs in the research group were equivalent to the pretreatment levels;for example,the GSH-Px and SOD levels were significantly higher,while the MDA and AOPP levels were lower.CONCLUSION Dual-modality endoscopy therapy(duodenoscopy and laparoscopy)is more effective than traditional laparotomy in the treatment of intra-and extrahepatic BDSs and has a lower risk of postoperative complications;significantly shortened surgical time;shorter gastrointestinal function recovery time;shorter hospital stay;and lower intraop-erative bleeding volume,while having a significant inhibitory effect on excessive serum inflammation and causing little postoperative oxidative stress.

Asymptomatic bile duct stones:The devil is in the details

Common bile duct(CBD)stones are a common biliary tract disease.For asymp-tomatic CBD stones,stone removal by endoscopic retrograde cholangiopancreato-graphy(ERCP)is recommended in available guidelines.Because asymptomatic CBD stones is a benign disease with no noticeable symptoms,the risk vs benefit strategy should be thoroughly considered before performing ERCP in these patients.Clinical care review,technical aspects of the procedure,and patient preferences should also be considered.

Nursing Effect of Rapid Rehabilitation Surgery Concept in Laparoscopic Surgery for Extrahepatic Bile Duct Stones

Objective: To explore the application value of rapid rehabilitation concept in patients with extrahepatic bile duct stones under laparoscopy during perioperative period. Methods: 90 patients with extrahepatic bile duct stones treated in our hospital from January 2022 to February 2023 were selected as the research object and randomly divided into the study group and the control group. The control group was given routine care, and the observation group was given rapid surgical rehabilitation care. The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time, hospitalization time and complication rate were compared between the two groups. The independent sample T test was used for the measurement data, and the x2 test was used for the counting data, and the difference was statistically significant (P Results: The postoperative anal exhaust time, first meal time, early activity time, pain time, abdominal drainage tube removal time and hospitalization time in the study group were shorter than those in the control group (all P Conclusion: The concept of rapid rehabilitation can significantly improve the perioperative nursing effect of patients with extrahepatic bile duct stones and accelerate their rehabilitation, which is worth improving and popularizing.

Comprehensive review on small common bile duct stones

Common bile duct stones are among the most common conditions encountered by endoscopists.Therefore,it is well researched;however,some items,such as indications for endoscopic papillary balloon dilatation(EPBD),safety of EPBD and endoscopic sphincterotomy in patients receiving dual antiplatelet therapy or direct oral anticoagulant,selection strategy for retrieval balloons and baskets,lack adequate evidence.Therefore,the guidelines have been updated with new research,while others remain unchanged due to weak evidence.In this review,we comprehensively summarize the standard methods in guidelines and new findings from recent studies on papillary dilation,stone retrieval devices,difficult-to-treat cases,troubleshooting during the procedure,and complicated cases of cholangitis,cholecystolithiasis,or distal biliary stricture.

Long-term outcomes of endoscopic papillary large-balloon dilation(12-15 mm)with or without limited sphincterotomy for removal of bile duct stones

Background:Limited endoscopic sphincterotomy with large balloon dilation(ES-LBD)and endoscopic papillary large-balloon dilation(EPLBD)have been proven safe and effective for removal of bile duct stones.However,the long-term outcomes are not clear.The aim of this study was to assess the long-term outcomes of EPLBD(12-15 mm)with or without limited sphincterotomy for removal of common bile duct(CBD)stones.Methods:Patients with EPLBD or ES-LBD referred for the removal of bile-duct stones between June 2008 and August 2020 were retrospectively reviewed.Complete stone clearance,endoscopic retrograde cholangiopancreatography(ERCP)-related adverse events,and late biliary complications during long-term follow-up were analyzed.Results:Basic patient characteristics were not significantly different between the groups that underwent EPLBD(n=168)and ES-LBD(n=57).EPLBD compared with ES-LBD resulted in similar outcomes in terms of overall successful stone removal(99.4%vs.100%,P=1.00)and ERCP-related adverse events(7.7%vs.5.3%,P=0.77).The mean duration of the follow-up were 113.6 months and 106.7 months for patients with EPLBD and ES-LBD,respectively(P=0.13).There was no significant difference between EPLBD and ES-LBD in the incidence of stone recurrence[20(11.9%)vs.9(15.8%);P=0.49].Multivariate analysis showed that a diameter of CBD≥15 mm(OR=3.001;95%CI:1.357-6.640;P=0.007)was an independent risk factor for stone recurrence.Conclusions:The application of a large balloon(12-15 mm)via EPLBD is an effective and safe alternative to ES-LBD for extraction of large CBD stones.Endoscopic sphincterotomy prior to EPLBD may be unnec-essary.A diameter of CBD≥15 mm is a risk factor of stone recurrence.

Cholangioscopy-assisted extraction through novel papillary support for small-calibre and sediment-like common bile duct stones

BACKGROUND To date,endoscopic retrograde cholangiopancreatography has become a wellestablished treatment for common bile duct(CBD)stones.However,it is not suitable for some special patients,such as pregnant women,children or those who cannot stop taking anti-coagulation/anti-platelet agents because of radiation injury and the risk of postoperative bleeding resulting from endoscopic sphincterotomy.To overcome these two problems,this study introduced cholangioscopy-assisted extraction through a novel papillary support for small-calibre and sediment-like CBD stones.AIM To assess the feasibility and safety of cholangioscopy-assisted extraction through a novel papillary support(CEPTS)for small-calibre and sediment-like common bile duct(CBD)stones.METHODS This Retrospective study was approved by the Ethics Committee of the Chinese PLA General Hospital.We designed a covered single dumbbell-style papillary support between 2021 and 2022.Between July 2022 and September 2022,7 consecutive patients with small-calibre(cross diameter≤1.0 cm)or sediment-like CBD stones underwent CETPS procedures in our center.The clinical characteristics and treatment outcomes of these 7 patients were extracted from a prospectively collected database.And the related data were analyzed.Informed consent was obtained from all participating patients.RESULTS A total of 2 patients had yellow sediment-like CBD stones,and aspiration extraction was performed after the insertion of papillary support.Of the 5 patients with clumpy CBD stones(0.4-1.0 cm),2 underwent basket extraction under direct vision for a single stone(0.5-1.0 cm,black and black grey),1 underwent balloon plus aspiration extraction under direct vision for 5 stones(0.4-0.6 cm,brown),and 2 underwent aspiration extraction only for a single stone(0.5-0.6 cm,yellow,none).Technical success,namely,no residual stones in the CBD or left and right hepatic ducts,was achieved in all 7 cases(100%).The median operating time was 45.0 minutes(range 13.0–87.0 minutes).Postoperative pancreatitis(PEP)occurred in one case(14.3%).Hyperamylasaemia without abdominal pain was noted in 2 of 7 patients.No residual stones or cholangitis were found during the follow-up.CONCLUSION CETPS appeared to be feasible to treat patients with small-calibre or sediment-like CBD stones.Patients,especially pregnant women and those who cannot stop anticoagulation/anti-platelet agents,could benefit from this technique.

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones?

AIM:To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into the common bile duct.METHODS:Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever,and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes.These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP.All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.RESULTS:No stones were detected by ERCP in any patient,confi rming the results of MRCP.CONCLUSION:When clinical symptoms improve,blood biochemical parameters have normalized,and MRCP shows there are no stones in the common bile duct,it can be considered the stone has spontaneously passed and thus ERCP is not necessary.

Endoscopic papillary large balloon dilation for removal of bile duct stones

AIM: To investigate the efficacy and outcomes of endoscopic papillary large balloon dilation (EPLBD) for bile duct stones in a multicenter prospective study.

Remaining issues of recommended management in current guidelines for asymptomatic common bile duct stones

Current guidelines for treating asymptomatic common bile duct stones(CBDS)recommend stone removal,with endoscopic retrograde cholangiopan-creatography(ERCP)being the first treatment choice.When deciding on ERCP treatment for asymptomatic CBDS,the risk of ERCP-related complications and outcome of natural history of asymptomatic CBDS should be compared.The incidence rate of ERCP-related complications,particularly of post-ERCP pancreatitis for asymptomatic CBDS,was reportedly higher than that of symptomatic CBDS,increasing the risk of ERCP-related complications for asymptomatic CBDS compared with that previously reported for biliopancreatic diseases.Although studies have reported short-to middle-term outcomes of natural history of asymptomatic CBDS,its long-term natural history is not well known.Till date,there are no prospective studies that determined whether ERCP has a better outcome than no treatment in patients with asymptomatic CBDS or not.No randomized controlled trial has evaluated the risk of early and late ERCP-related complications vs the risk of biliary complications in the wait-and-see approach,suggesting that a change is needed in our perspective on endoscopic treatment for asymptomatic CBDS.Further studies examining long-term complication risks of ERCP and wait-and-see groups for asymptomatic CBDS are warranted to discuss whether routine endoscopic treatment for asymptomatic CBDS is justified or not.

Two-stage vs single-stage management for concomitant gallstones and common bile duct stones

AIM:To evaluate the safety and effectiveness of twostage vs single-stage management for concomitant gallstones and common bile duct stones.METHODS:Four databases,including PubMed,Embase,the Cochrane Central Register of Controlled Trials and the Science Citation Index up to September 2011,were searched to identify all randomized controlled trials(RCTs).Data were extracted from the studies by two independent reviewers.The primary outcomes were stone clearance from the common bile duct,postoperative morbidity and mortality.The secondary outcomes were conversion to other procedures,number of procedures per patient,length of hospital stay,total operative time,hospitalization charges,patient acceptance and quality of life scores.RESULTS:Seven eligible RCTs [five trials(n = 621) comparing preoperative endoscopic retrograde cholangiopancreatography(ERCP)/endoscopic sphincterotomy(EST) + laparoscopic cholecystectomy(LC) with LC + laparoscopic common bile duct exploration(LCBDE);two trials(n = 166) comparing postoperative ERCP/EST + LC with LC + LCBDE],composed of 787 patients in total,were included in the final analysis.The metaanalysis detected no statistically significant difference between the two groups in stone clearance from the common bile duct [risk ratios(RR) =-0.10,95% confidence intervals(CI):-0.24 to 0.04,P = 0.17],postoperative morbidity(RR = 0.79,95% CI:0.58 to 1.10,P = 0.16),mortality(RR = 2.19,95% CI:0.33 to 14.67,P = 0.42),conversion to other procedures(RR = 1.21,95% CI:0.54 to 2.70,P = 0.39),length of hospital stay(MD = 0.99,95% CI:-1.59 to 3.57,P = 0.45),total operative time(MD = 12.14,95% CI:-1.83 to 26.10,P = 0.09).Two-stage(LC + ERCP/EST) management clearly required more procedures per patient than single-stage(LC + LCBDE) management.CONCLUSION:Single-stage management is equivalent to two-stage management but requires fewer procedures.However,patient's condition,operator's expertise and local resources should be taken into account in making treatment decisions.

Recurrence of choledocholithiasis following endoscopic bile duct clearance: Long term results and factors associated with recurrent bile duct stones

AIMTo evaluate the rate of recurrence of symptomatic choledocholithiasis and identify factors associated with the recurrence of bile duct stones in patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (EST) for bile duct stone disease. METHODSAll patients who underwent ERCP and EST for bile duct stone disease and had their bile duct cleared from 1/1/2005 until 31/12/2008 was enrolled. All symptomatic recurrences during the study period (until 31/12/2015) were recorded. Clinical and laboratory data potentially associated with common bile duct (CBD) stone recurrence were retrospectively retrieved from patients&rsquo; files. RESULTSA total of 495 patients were included. Sixty seven (67) out of 495 patients (13.5%) presented with recurrent symptomatic choledocholithiasis after 35.28 &plusmn; 16.9 mo while twenty two (22) of these patients (32.8%) experienced a second recurrence after 35.19 &plusmn; 23.2 mo. Factors associated with recurrence were size (diameter) of the largest CBD stone found at first presentation (10.2 &plusmn; 6.9 mm vs 7.2 &plusmn; 4.1 mm, P = 0.024), diameter of the CBD at the first examination (15.5 &plusmn; 6.3 mm vs 12.0 &plusmn; 4.6 mm, P = 0.005), use of mechanical lithotripsy (ML) (P = 0.04) and presence of difficult lithiasis (P = 0.04). Periampullary diverticula showed a trend towards significance (P = 0.066). On the contrary, number of stones, angulation of the CBD, number of ERCP sessions required to clear the CBD at first presentation, more than one ERCP session needed to clear the bile duct initially and a gallbladder in situ did not influence recurrence. CONCLUSIONBile duct stone recurrence is a possible late complication following endoscopic stone extraction and CBD clearance. It appears to be associated with anatomical parameters (CBD diameter) and stone characteristics (stone size, use of ML, difficult lithiasis) at first presentation.

Large balloon dilation post endoscopic sphincterotomy in removal of difficult common bile duct stones:A literature review

Endoscopic sphincterotomy (ES) is the standard therapy in common bile duct (CBD) stones extraction. Large stones (&#x02265; 12 mm) or multiple stones extraction may be challenging after ES alone. Endoscopic sphincterotomy followed by large balloon dilation (ESLBD) has been described as an alternative to ES in these indications. Efficacy, safety, cost-effectiveness and technical aspects of the procedure have been here reviewed. PubMed and Google Scholar search resulted in forty-one articles dealing with CBD stone extraction with 12 mm or more dilation balloons after ES. ESLBD is at least as effective as ES, and reduces the need for additional mechanical lithotripsy. Adverse events rates are not statistically different after ESLBD compared to ES for pancreatitis, bleeding and perforation. However, particular attention should be paid in patients with CBD strictures, which is identified as a risk factor of perforation. ESLBD is slightly cost-effective compared to ES. A small sphincterotomy is usually performed, and may reduce bleeding rates compared to full sphincterotomy. Dilation is performed with 12-20 mm enteral balloons. Optimal inflation time is yet to be determined. The procedure can be performed safely even in patients with peri-ampullary diverticula and surgically altered anatomy. ESLBD is effective and safe in the removal of large CBD stones, however, small sphincterotomy might be preferred and CBD strictures should be considered as a relative contraindication.

Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones:A meta-analysis

AIM: To compare the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) with endoscopic sphincterotomy (EST) in retrieval of common bile duct stones (&#x02265; 10 mm).

Clinical usefulness of transpapillary removal of common bile duct stones by frequency doubled double pulse Nd:YAG laser

AIM: To study the efficacy and the safety of laser lithotripsy without direct visual control by using a balloon catheter in patients with bile duct stones that could not be extracted by standard technique. METHODS: The seventeen patients (7 male and 10 female; mean age 67.8 years) with difficult common bile duct (CBD) stones were not amenable for conventional endoscopic maneuvers such as sphincterotomy and mechanical lithotripsy were included in this study. Laser wavelengths of 532 nm and 1064 nm as a double pulse were applied with pulse energy of 120 mJ. The laser fiber was advanced under fluoroscopic control through the ERCP balloon catheter. Laser lithotripsy was continued until the fragment size seemed to be less than 10 mm. Endoscopic extraction of the stones and fragments was performed with the use of the Dormia basket and balloon catheter. RESULTS: Bile duct clearance was achieved in 15 of 17 patients (88%). The mean number of treatment sessions was 1.7 ± 0.6. Endoscopic stone removal could not be achieved in 2 patients (7%). Adverse effects were noted in three patients (hemobilia, pancreatitis, and cholangitis). CONCLUSION: The Frequency Doubled Double Pulse Nd:YAG (FREDDY) laser may be an effective and safe technique in treatment of difficult bile duct stones.

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones.To avoid serious complications,these stones should be removed.There is no consensus about the ideal management strategy for such patients.Traditionally,open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography(ERCP) and laparoscopic cholecystectomy(LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages.Minimally invasive approach could be done in either twosession(preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session(laparoscopic common bile duct exploration or LC with intraoperative ERCP).Most recent studies have found that both options are equivalent regarding safety and efficacy but the singlesession approach is associated with shorter hospital stay,fewer procedures per patient,and less cost.Consequently,single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist.However,the management strategy should be tailored according to many variables,such as available resources,experience,patient characteristics,clinical presentations,and surgical pathology.