BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in pat...BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.展开更多
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 ...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.展开更多
AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treate...AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.展开更多
Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred t...Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.展开更多
Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones...Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.展开更多
Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outco...Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outcomes. However, there is no consensus with regard to the ballooning time. The aim of our study was to evaluate the efficacy and safety of immediate balloon deflation in EPLBD for the treatment of difficult bile duct stone. Methods: This was a retrospective study of 80 consecutive patients with bile duct stones who were treated with an immediate balloon deflation method in EPLBD combined with endoscopic sphincterotomy (EST) between January 2010 and December 2012. Overall success rate, success rate at first ERCP, and the frequency of mechanical lithotripsy for complete stone removal were assessed for efficacy and safety was evaluated by assessing major complications. Results: Overall success rate for complete stone removal was high (78/80, 97.5%) and success rate for complete stone removal at first ERCP was 86.3% (69/80). The use of mechanical lithotripsy was 0% (0/80). The overall complication rate was favorable (5/80, 6.3%). PostERCP pancreatitis was observed in 3 patients (two: mild, one: moderate). In subgroup analysis, the presence of periampullary diverticulum was the only factor affecting the success rate at first ERCP. Conclusion: This study demonstrated the favorable outcome of immediate balloon deflation for treatment of difficult CBD stones and can be considered for clinical application.展开更多
Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to r...Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.展开更多
AIM:To describe characteristics of a poorly expandable(PE) common bile duct(CBD) with stones on endoscopic retrograde cholangiography.METHODS:A PE bile duct was characterized by a rigid and relatively narrowed distal ...AIM:To describe characteristics of a poorly expandable(PE) common bile duct(CBD) with stones on endoscopic retrograde cholangiography.METHODS:A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment.Between 2003 and 2006,endoscopic retrograde cholangiography(ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital.Patients with characteristic PE bile duct on ERC were identified from the database.Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS:A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study.The median patient age was 45 years(range,20 to 92 years);66.7% of the patients were men.The diameters of the widest non-PE CBD segment,the PE segment,and the largest stone were 14.3 ± 4.9 mm,5.8 ± 1.6 mm,and 11.2 ± 4.7 mm,respectively.The length of the PE segment was 39.7 ± 15.4 mm(range,12.3 mm to 70.9 mm).To remove the CBD stone(s) completely,mechanical lithotripsy was required in 25(83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature.The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy.Post-ERC complications occurred in 4 cases:pancreatitis in 1,cholangitis in 2,and an impacted Dormia basket with cholangitis in 1.Two(6.7%) of the 28 patients developed recurrent CBD stones at follow-up(50 ± 14 mo) and were successfully managed with therapeutic ERC.CONCLUSION:Patients with a PE duct frequently require mechanical lithotripsy for stones extraction.To retrieve stones successfully and avoid complications,these patients should be identified during ERC.展开更多
文摘BACKGROUND Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts.AIM To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.METHODS Data from 1289 endoscopic retrograde cholangiopancreatography(ERCP)procedures were obtained from two prospective studies.While 258 cases had difficult stones(>1 cm,multiple>8,impacted,or having a thin distal duct),191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy.Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number.Primary outcomes were clearance rate at first ERCP and complications.RESULTS Of the 191 patients(122 women and 69 men;mean age:60 years)who underwent biliary dilation for difficult stones,113(59%)had a nondilated or tapered distal duct.Patients with a dilated distal duct were older than those with nondilated distal ducts(mean 68 and 52 years of age,respectively;P<0.05),had more stones(median 4 and 2 stones per patient,respectively;P<0.05),and had less need for additional mechanical lithotripsy(6.4%vs 25%,respectively;P<0.05).Clearance rate at first ERCP was comparable between patients with a dilated(73/78;94%)and nondilated distal ducts(103/113;91%).Procedures were faster in patients with a dilated distal duct(mean 17 vs 24 min,respectively;P<0.005).Complications were similar in both groups(6.4%vs 7.1%,respectively).CONCLUSION Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.
文摘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.
文摘AIM:To evaluate the efficacy of extracorporeal shock wave lithotripsy(ESWL)for the management of refractory bile duct cholelithiasis in a third level referral centre.METHODS:The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus,SIEMENS)from October 1990 to April 2005 were evaluated.All patients were monitored during the procedure and antibiotics were administered in case of cholangitis.Theχ 2 test and logistic regression analysis were performed as appropriate.RESULTS:Two hundred and fourteen patients(102 males,112 females;mean age 74.8±0.84 years-single stone 97,multiple stones 117)underwent ESWL.The mean number of sessions and shock waves were 3.5 ±0.13 and 3477.06±66.17,respectively.The maximum stone size was 5 cm.Complete stone clearance was achieved in 192(89.7%)patients.Of the remain-ing patients 15 required surgery,2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance.Age,sex and stone characteristics were not related to treatment outcome.Major complications occurred in two patients(haemobilia and rectal bleeding) and minor complications in 25(3 vomiting,22 arrhythmias).No procedure-related deaths occurred.CONCLUSION:ESWL is a safe and effective technique for clearance of refractory bile duct stones.
文摘Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.
文摘Endoscopy is widely accepted as the first treatment option in the management of bile duct stones.In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones.Most biliary stones can be removed with an extraction balloon,extraction basket or mechanical lithotripsy after endoscopic sphincterotomy.Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients.Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed.Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.
文摘Background/Aims: Recently, endoscopic papillary large balloon dilation (EPLBD) using a large balloon (12 - 20 mm) for extraction of difficult common bile duct (CBD) stones has been widely accepted with favorable outcomes. However, there is no consensus with regard to the ballooning time. The aim of our study was to evaluate the efficacy and safety of immediate balloon deflation in EPLBD for the treatment of difficult bile duct stone. Methods: This was a retrospective study of 80 consecutive patients with bile duct stones who were treated with an immediate balloon deflation method in EPLBD combined with endoscopic sphincterotomy (EST) between January 2010 and December 2012. Overall success rate, success rate at first ERCP, and the frequency of mechanical lithotripsy for complete stone removal were assessed for efficacy and safety was evaluated by assessing major complications. Results: Overall success rate for complete stone removal was high (78/80, 97.5%) and success rate for complete stone removal at first ERCP was 86.3% (69/80). The use of mechanical lithotripsy was 0% (0/80). The overall complication rate was favorable (5/80, 6.3%). PostERCP pancreatitis was observed in 3 patients (two: mild, one: moderate). In subgroup analysis, the presence of periampullary diverticulum was the only factor affecting the success rate at first ERCP. Conclusion: This study demonstrated the favorable outcome of immediate balloon deflation for treatment of difficult CBD stones and can be considered for clinical application.
文摘Background: Duodenoscope-related multidrug-resistant organism(MDRO) infections raise concerns. Disposable duodenoscopes have been recently introduced in the market and approved by regulatory agencies with the aim to reduce the risk of endoscopic retrograde cholangiopancreatography(ERCP) associated infections. The aim of this study was to evaluate the outcome of procedures performed with single-use duodenoscopes in patients with clinical indications to single-operator cholangiopancreatoscopy. Methods: This is a multicenter international, retrospective study combining all patients who underwent complex biliopancreatic interventions using the combination of a single-use duodenoscope and a single-use cholangioscope. The primary outcome was technical success defined as ERCP completion for the intended clinical indication. Secondary outcomes were procedural duration, rate of cross-over to reusable duodenoscope, operator-reported satisfaction score(1 to 10) on performance rating of the single-use duodenoscope, and adverse event(AE) rate. Results: A total of 66 patients(26, 39.4% female) were included in the study. ERCP was categorized according to ASGE ERCP grading system as 47(71.2%) grade 3 and 19(28.8%) grade 4. The technical success rate was 98.5%(65/66). Procedural duration was 64(interquartile range 15-189) min, cross-over rate to reusable duodenoscope was 1/66(1.5%). The satisfaction score of the single-use duodenoscope classified by the operators was 8.6 ± 1.3 points. Four patients(6.1%) experienced AEs not directly related to the single-use duodenoscope, namely 2 post-ERCP pancreatitis(PEP), 1 cholangitis and 1 bleeding.Conclusions: Single-use duodenoscope is effective, reliable and safe even in technically challenging procedures with a non-inferiority to reusable duodenoscope, making these devices a viable alternative to standard reusable equipment.
文摘AIM:To describe characteristics of a poorly expandable(PE) common bile duct(CBD) with stones on endoscopic retrograde cholangiography.METHODS:A PE bile duct was characterized by a rigid and relatively narrowed distal CBD with retrograde dilatation of the non-PE segment.Between 2003 and 2006,endoscopic retrograde cholangiography(ERC) images and chart reviews of 1213 patients with newly diagnosed CBD stones were obtained from the computer database of Therapeutic Endoscopic Center in Chang Gung Memorial Hospital.Patients with characteristic PE bile duct on ERC were identified from the database.Data of the patients as well as the safety and technical success of therapeutic ERC were collected and analyzed retrospectively.RESULTS:A total of 30 patients with CBD stones and characteristic PE segments were enrolled in this study.The median patient age was 45 years(range,20 to 92 years);66.7% of the patients were men.The diameters of the widest non-PE CBD segment,the PE segment,and the largest stone were 14.3 ± 4.9 mm,5.8 ± 1.6 mm,and 11.2 ± 4.7 mm,respectively.The length of the PE segment was 39.7 ± 15.4 mm(range,12.3 mm to 70.9 mm).To remove the CBD stone(s) completely,mechanical lithotripsy was required in 25(83.3%) patients even though the stone size was not as large as were the difficult stones that have been described in the literature.The stone size and stone/PE segment diameter ratio were associated with the need for lithotripsy.Post-ERC complications occurred in 4 cases:pancreatitis in 1,cholangitis in 2,and an impacted Dormia basket with cholangitis in 1.Two(6.7%) of the 28 patients developed recurrent CBD stones at follow-up(50 ± 14 mo) and were successfully managed with therapeutic ERC.CONCLUSION:Patients with a PE duct frequently require mechanical lithotripsy for stones extraction.To retrieve stones successfully and avoid complications,these patients should be identified during ERC.