Predicting Clearance of ‘Difficult’ Biliary Stones in the Cholangioscopy ERA

Aims A number of predictors of failure of biliary stone clearance at endoscopic retrograde cholangio pancreatography (ERCP) are known, including stones > 15mm, stones above strictures, Mirrizzi syndrome and intrahepatic stones(1). The introduction of single operator cholangioscopy (SOC) has improved the ability to treat difficult biliary stone disease(2). However, there have been no studies looking at predicting success or failure of biliary stone disease in the era of SOC.

Methods All patients undergoing ERCP with Spyglass DS/DSII™ SOC for biliary stones at a high-volume UK tertiary referral centre between January 2015 to April 2019 were enrolled. Using clinical records and the endoscopy reporting tool; patient demographics, indication for cholangioscopy and procedural success rate were recorded. Success was defined as endoscopist assessment of: incomplete clearance requiring stent insertion, incomplete clearance not requiring stent insertion, and complete clearance of the biliary tree.

Results 256 procedures were performed in 211 patients (mean 63.7 years, 60 % female). Seven procedures were excluded due to incomplete documentation. All patients had had previously unsuccessful attempts at stone clearance

Procedure indications included: extrahepatic biliary stones (n = 200), stones above strictures (n= 19), intrahepatic stones (n = 12) and Mirizzi syndrome (n = 25). Complete stone clearance was achieved in 58 %, 42 %, 75 % and 56 % respectively. However, where stone fragmentation was felt to be sufficient to not require stent insertion these rates increased to 62 %, 58 %, 75 % and 80 % respectively.

Tab. 1

Indication for procedure	Numbers	Complete Clearance	Partial Clearance without stents	Partial Clearance with stents
CBD Stones	200	116 (58 %)	8 (4 %)	67 (33.5 %)
Stones above Stricture	19	8 (42.1 %)	3 (15.8 %)	7 (36.8 %)
Intra Hepatic Stones	12	9 (75 %)	0 (0 %)	3 (25 %)
Mirizzi	25	14 (56 %)	6 (24 %)	5 (20 %)

Conclusions SOC has an important role to play in biliary stone disease where conventional ERCP has failed. It may particularly advance stone clearance in the setting of Mirizzi syndrome and intra hepatic stones. Stones above strictures remain a challenge, even with SOC. Patient selection remains vital and all cases should be discussed in an MDM prior to undertaking SOC.

Citation: Martin H, Patel S, Virdee P et al. OP188 PREDICTING CLEARANCE OF ‘DIFFICULT’ BILIARY STONES IN THE CHOLANGIOSCOPY ERA. Endoscopy 2021; 53: S78.