Recent advances in endoscopic management of difficult bile duct stones

Abstract

Endoscopic treatment is now recognized worldwide as the firstline treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother-baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single-use cholangioscope system -the SpyGlass direct visualization system -are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilation has been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound-guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.

Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience

“…Allowing for some advantages such as the repeatability and no restriction in stone size, it has displayed several drawbacks as limited efficacy (i.e. variable stone clearance 73-90% [Yasuda and Itoi, 2013]), long treatment duration, number of sessions needed to complete stone clearance (even more than 5 [Muratori et al 2010]) and complications (i.e. bleeding, arrhythmias) [Muratori et al 2010].…”

“…It is noteworthy that hepatolithiasis may lead to recurrent cholangitis, biliary cirrhosis and cholangiocarcinoma [Yasuda and Itoi, 2013].…”

“…Possible factors leading to difficult bile duct stone are: periampullary diverticula, previous surgical operation, large size stones, presence of multiple stones, stones above a stricture, intrahepatic stones, impacted stones and clinical status of the patient [Yasuda and Itoi, 2013]. Several techniques have been described to cope with difficult bile duct stones such as per-oral cholangioscopy (POCS) with laser or electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy, endoscopic papillary large balloon dilatation, enteroscopy, percutaneous transhepatic cholangioscopy (PTCS), endoscopic ultrasound guided antegrade technique and stenting [Yasuda and Itoi, 2013;Erim et al 2013;Buxbaum, 2013;Kim et al 2013;Trikudanathan et al 2013]. Currently there are a few reports on PTCS with laser or EHL and they mainly describe treatment of common bile duct (CBD) stones.…”

Treatment for difficult bile duct stones: Balloon enteroscopy assisted‐endoscopic retrograde cholangiopancreatography

“…[1][2][3] However, BDS extraction has been occasionally difficult because of limited device selection. Herein, we present a case of large BDS successfully managed by using multi-step EUS-AG.…”

Endoscopic Balloon Dilatation vs. Sphincterotomy in Cases of Calcular Obstructive Jaundice during Endoscopic Retrograde Cholangio Pancreatography

“…However, when faced with more challenging situations, additional techniques such as mechanical lithotripsy may be utilized. Furthermore, ES and stone removal can result in adverse events, including bleeding, pancreatitis, perforation and cholangitis [4].…”