Digital cholangioscopy can detect residual biliary stones missed by occlusion cholangiogram in ERCP: a prospective tandem study

Abstract

Background and study aims After stone removal in endoscopic retrograde cholangiopancreatography (ERCP), an occlusion cholangiogram (OC) is performed to confirm bile duct clearance. OC can miss residual stones that can lead to recurrent biliary symptoms. The aim of this study was to assess if digital peroral cholangioscopy (POC) increased the diagnostic yield of residual biliary stones that are missed with OC.

Patients and methods Patients having ERCP performed for choledocholithiasis were enrolled into the study only if they had one of the following criteria: dilated bile duct ≥ 12 mm and/or if lithotripsy was being performed. An OC was performed to confirm duct clearance after removal of stones followed by POC, based on inclusion criteria. The incremental yield of biliary stones missed by OC but confirmed by POC was then measured. A total of 96 POC procedures were performed on 93 patients in two tertiary care centers.

Results Residual biliary stones were found in 34 % of cases. The average bile duct size in cases with residual stones was 15.1 mm ± 0.7 mm. One- to three-mm stones were found in 41 % of cases, 4- to 7-mm stones in 45 % of cases, and ≥ 8-mm stones in 14 % of cases. Lithotripsy was performed in 13 % of cases and was significantly associated with residual stones (30 % vs. 3 %, P < 0.001).

Conclusions Occlusion cholangiogram can miss residual stones in patients with dilated bile ducts and those receiving lithotripsy. Digital POC can increase the yield of residual stone detection in these patients and should be considered to confirm clearance of stones. (ClinicalTrials.gov-NCT03482375).

• References

• 1 Everhart JE, Khare M, Hill M. et al. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117: 632-639
• 2 Lacaine F, Corlette MB, Bismuth H. Preoperative evaluation of the risk of common bile duct stones. Arch Surg 1980; 115: 1114-1116
• 3 Neuhaus H, Feussner H, Ungeheuer A. et al. Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy. Endoscopy 1992; 24: 745-749
• 4 Awadallah NSBS, Chen YKMD, Piraka CMD. et al. Is there a role for cholangioscopy in patients with primary sclerosing cholangitis?. Am J Gastroenterol 2006; 101: 284-291
• 5 Chen YK, Parsi MA, Binmoeller KF. et al. Single-operator cholangioscopy in patients requiring evaluation of bile duct disease or therapy of biliary stones (with videos). Gastrointest Endosc 2011; 74: 805-814
• 6 Itoi T, Sofuni A, Itokawa F. et al. Evaluation of residual bile duct stones by peroral cholangioscopy in comparison with balloon-cholangiography. Dig Endosc 2010; 22 (Suppl. 01) S85-s89
• 7 Lee YN, Moon JH, Choi HJ. et al. Direct peroral cholangioscopy using an ultraslim upper endoscope for management of residual stones after mechanical lithotripsy for retained common bile duct stones. Endoscopy 2012; 44: 819-824
• 8 Maple JT, Ben-Menachem T, Anderson MA. et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71: 1-9
• 9 Chen YK. Preclinical characterization of the Spyglass peroral cholangiopancreatoscopy system for direct access, visualization, and biopsy. Gastrointest Endosc 2007; 65: 303-311
• 10 Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 65: 832-841
• 11 Komanduri S, Thosani N, Abu Dayyeh BK. et al. Cholangiopancreatoscopy. Gastrointest Endosc 2016; 84: 209-221
• 12 Navaneethan U, Hasan MK, Kommaraju K. et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc 2016; 84: 649-655
• 13 Othman MO, Guerrero R, Elhanafi S. et al. A prospective study of the risk of bacteremia in directed cholangioscopic examination of the common bile duct. Gastrointestinal endoscopy 2016; 83: 151-157
• 14 Chandrasekhara V, Khashab MA. ASGE Standards of Practice Committee. et al. Adverse events associated with ERCP. Gastrointest Endosc 2017; 85: 32-47
• 15 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 16 Ainsworth AP, Rafaelsen SR, Wamberg PA. et al. Is there a difference in diagnostic accuracy and clinical impact between endoscopic ultrasonography and magnetic resonance cholangiopancreatography?. Endoscopy 2003; 35: 1029-1032
• 17 de Ledinghen V, Lecesne R, Raymond JM. et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study. Gastrointest Endosc 1999; 49: 26-31
• 18 Fernandez-Esparrach GMDPD, Gines AMDPD, Sanchez MMD. et al. Comparison of Endoscopic Ultrasonography and Magnetic Resonance Cholangiopancreatography in the Diagnosis of Pancreatobiliary Diseases: A Prospective Study. Am J Gastroenterol 2007; 102: 1632-1639
• 19 Garrow D, Miller S, Sinha D. et al. Endoscopic ultrasound: a meta-analysis of test performance in suspected biliary obstruction. Clin Gastroenterol Hepatol 2007; 5: 616-623
• 20 Kondo S, Isayama H, Akahane M. et al. Detection of common bile duct stones: comparison between endoscopic ultrasonography, magnetic resonance cholangiography, and helical-computed-tomographic cholangiography. Euro J Radiol 2005; 54: 271-275
• 21 Materne R, Van Beers BE, Gigot JF. et al. Extrahepatic biliary obstruction: magnetic resonance imaging compared with endoscopic ultrasonography. Endoscopy 2000; 32: 3-9
• 22 Scheiman JM, Carlos RC, Barnett JL. et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis. Am J Gastroenterol 2001; 96: 2900-2904
• 23 Tse F, Liu L, Barkun AN. et al. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc 2008; 67: 235-244
• 24 Liu CL, Lo CM, Chan JK. et al. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointest Endosc 2000; 51: 28-32
• 25 Shimizu S, Tada M, Kawai K. Diagnostic ERCP. Endoscopy 1994; 26: 88-92
• 26 Awadallah NS, Chen YK, Piraka C. et al. Is there a role for cholangioscopy in patients with primary sclerosing cholangitis?. Am J Gastroenterol 2006; 101: 284-291
• 27 Huang SW, Lin CH, Lee MS. et al. Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope. World J Gastroenterol 2013; 19: 4966-4972
• 28 Ando T, Tsuyuguchi T, Okugawa T. et al. Risk factors for recurrent bile duct stones after endoscopic papillotomy. Gut 2003; 52: 116-121
• 29 Cheon YK, Lehman GA. Identification of risk factors for stone recurrence after endoscopic treatment of bile duct stones. Eur J Gastroenterol Hepatol 2006; 18: 461-464
• 30 Saito M, Tsuyuguchi T, Yamaguchi T. et al. Long-term outcome of endoscopic papillotomy for choledocholithiasis with cholecystolithiasis. Gastrointest Endosc 2000; 51: 540-545
• 31 Tsuchiya S, Tsuyuguchi T, Sakai Y. et al. Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy. J Gastroenterol Hepatol 2008; 23: 1590-1595