Early cholangioscopy-guided lithotripsy for clearance of biliary stones associated with narrow lower bile duct

Abstract

Background and study aims

Stones larger than the distal common bile duct (CBD) are difficult to remove with conventional techniques. Large papillary balloon dilatation (> 12 mm) of the biliary sphincter is an effective technique for stone removal but is associated with risk of leak in patients with narrower lower CBD. Mechanical or cholangioscopy-guided lithotripsy has been used in this situation for clearance of the bile duct. In the present study, we report outcomes of early cholangioscopy-guided lithotripsy in patients with narrow lower CBD compared with stone size.

Patients and methods

The present study is a retrospective analysis of prospectively collected data from all patients with large proximal stones with a narrow lower bile duct who underwent digital cholangioscopy and electrohydraulic lithotripsy (EHL). Outcomes were proportion of patients with complete bile duct clearance after the first session of electrohydraulic lithotripsy, mean number of EHL sessions for complete clearance, and complications.

Results

Eighty-one patients with mean age 54 ± 17 years underwent digital cholangioscopy and EHL. Mean stone size was 14.02 ± 3.5 mm and 71 patients (87.7%) had a stone only in the bile duct. Three (3.7%) and seven patients (8.6%) had stones also in the cystic duct and intrahepatic ducts, respectively. Balloon sphincteroplasty never exceeding distal CBD size was performed in 12 patients (14.8%). Complete stone clearance was achieved in 78 patients (96.3%) after a single session. Mean number of EHL sessions were 1.04 ± 0.19. Three patients developed mild adverse events, which were managed conservatively.

Conclusions

Early upfront digital cholangioscopy with EHL has high efficacy and safety for stone clearance after a single session in patients with narrow distal CBD.

Graphical abstract

Keywords

Pancreatobiliary (ERCP/PTCD) - Cholangioscopy - Stones - ERC topics

Publikationsverlauf

Eingereicht: 27. September 2024

Angenommen nach Revision: 26. Januar 2025

Accepted Manuscript online:
06. März 2025

Artikel online veröffentlicht:
04. April 2025

• References

• 1 Shabanzadeh DM, Sørensen LT, Jørgensen T. A prediction rule for risk stratification of incidentally discovered gallstones: Results from a large cohort study. Gastroenterology 2016; 150: 156-167 e1
• 2 Stinton LM, Myers RP, Shaffer EA. Epidemiology of gallstones. Gastroenterol Clin North Am 2010; 39: 157-169
• 3 Sivak MV. Endoscopic management of bile duct stones. Am J Surg 1989; 158: 228-240
• 4 Wongkanong C, Patumanond J, Ratanachu-Ek T. et al. Common bile duct stone-related parameters and their potential prognostic values for stone extraction requiring endoscopic papillary large balloon dilation. JGH Open Ratana Chu Access J Gastroenterol Hepatol 2023; 7: 16-23
• 5 Lee SH, Park JK, Yoon WJ. et al. How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?. Scand J Gastroenterol 2007; 42: 1006-1010
• 6 Sharma SS, Jain P. Should we redefine large common bile duct stone?. World J Gastroenterol 2008; 14: 651-652
• 7 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491
• 8 Park SJ, Kim JH, Hwang JC. et al. Factors predictive of adverse events following endoscopic papillary large balloon dilation: results from a multicenter series. Dig Dis Sci 2013; 58: 1100-1109
• 9 Kim TH, Kim JH, Seo DW. et al. International consensus guidelines for endoscopic papillary large-balloon dilation. Gastrointest Endosc 2016; 83: 37-47
• 10 Ding J, Li F, Zhu HY. et al. Endoscopic treatment of difficult extrahepatic bile duct stones, EPBD or EST: An anatomic view. World J Gastrointest Endosc 2015; 7: 274-277
• 11 Buxbaum J, Sahakian A, Ko C. et al. Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc 2018; 87: 1050-1060
• 12 Alrajhi S, Barkun A, Adam V. et al. Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective. Ther Adv Gastroenterol 2021; 14
• 13 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 14 Fujita Y, Iwasaki A, Sato T. et al. Feasibility of endoscopic papillary large balloon dilation in patients with difficult bile duct stones without dilatation of the lower part of the extrahepatic bile duct. Gut Liver 2017; 11: 149-155
• 15 Angsuwatcharakon P, Kulpatcharapong S, Ridtitid W. et al. Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study. Endoscopy 2019; 51: 1066-1073
• 16 Deprez PH, Garces Duran R, Moreels T. et al. The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures. Endoscopy 2018; 50: 109-118
• 17 Nelles SE, Haber GB, Kim YI. et al. Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones. Am J Gastroenterol 2004; 99: 2330-2334
• 18 Sethi A, Chen YK, Austin GL. et al. ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc 2011; 73: 251-256
• 19 Kamiyama R, Ogura T, Okuda A. et al. Electrohydraulic Lithotripsy for difficult bile duct stones under endoscopic retrograde cholangiopancreatography and peroral transluminal cholangioscopy guidance. Gut Liver 2018; 12: 457-462