Endoscopic retrograde cholangiopancreatography for stone burden in the bile and pancreatic ducts

Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model

Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.

Efficacy of Single-Operator Cholangioscopy-Guided Lithotripsy Compared With Large Balloon Sphincteroplasty in Management of Difficult Bile Duct Stones in a Randomized Trial

BACKGROUND & AIMS

Although single-operator cholangioscopy (SOC)-guided lithotripsy and large balloon sphincteroplasty (LBS)-based techniques are effective rescue measures, the ideal approach to management of difficult bile duct stones is unclear. We conducted a randomized trial to compare the effectiveness of SOC-guided lithotripsy and LBS-based approaches for endoscopic management of difficult bile duct stones.

METHODS

Patients with difficult bile duct stones who failed retrieval using balloon or basket were randomly assigned to groups that received SOC-guided laser lithotripsy (SOC-LL, n = 33) or LBS (n = 33), from June 2016 through August 2018. When assigned treatment was unsuccessful, patients underwent mechanical lithotripsy before crossing over to the other group. The main outcome was treatment success, defined as ability to clear the duct in 1 session. Secondary outcomes were adverse events and treatment costs.

RESULTS

A higher proportion of patients in the SOC-LL group had treatment success (93.9%) than in the LBS group (72.7%; P = .021). On multiple logistic regression analysis, treatment success was significantly associated with use of SOC-LL (odds ratio [OR], 8.7; 95% CI, 1.3-59.3; P = .026), stone to extrahepatic bile duct ratio of 1 or less (OR, 28.8; 95% CI, 1.2-687.6; P = .038), and lack of a tapered bile duct (OR, 26.9; 95% CI, 1.3-558.2; P = .034). There was no significant difference between groups in adverse events (9.1% in the SOC-LL group vs 3.0% in the LBS group, P = .61) or overall treatment cost ($16,684 in the SOC-LL group vs $10,626 in the LBS group; P = .097).

CONCLUSIONS

In a randomized trial of patients with difficult bile stones that cannot be cleared by standard maneuvers, SOC-guided lithotripsy leads to duct clearance in a significantly higher proportion of patients than LBS-particularly when stone size exceeds the diameter of the extrahepatic bile duct. Adjunct lithotripsy might be required in patients with tapered distal bile duct, because LBS alone is less likely to be successful. ClinicalTrials.gov no: NCT00852072.

Endoscopic papillary large balloon dilation after endoscopic sphincterotomy for treatment of common bile duct stones: Effects of different dilation durations

AIM: To investigate the effects of different dilation durations on the efficacy and safety of endoscopic papillary large balloon dilation (EPLBD) after endoscopic sphincterotomy (EST) for the treatment of common bile duct (CBD) stones.

METHODS: Ninety patients with CBD stones who received EPLBD from April 2012 to September 2013 were recruited in the study and randomized into three groups based on the balloon dilation duration: 0 min group, 1 min group, and 5 min group. The rates of successful stone removal and mechanical lithotripsy, the procedure time and early complications were compared among the groups.

RESULTS: One patient was excluded due to intolerance of dilation pain; stone extraction was successful in all the other 89 patients. Stone clearance rates after single session in the three groups were all 100%. The rates of mechanical lithotripsy were 14.8% (4/27), 6.3% (2/32) and 20% (6/30) in the 0, 1 and 5 min groups, respectively (P = 0.25). The operative times were 29.5 min ± 8.62 min, 24.3 min ± 6.27 min and 28.6 min ± 7.58 min in 0, 1 and 5 min groups (P = 0.02). The rate of hyperamylasemia was 14.8% (4/27) in the 0 min group, 0% (0/32) in the 1 min group and 10% (3/30) in the 5 min group (P = 0.03). No hemorrhage, perforation, cholangitis or acute pancreatitis occurred in any group.

CONCLUSION: EPLBD is an effective and safe method for the treatment of CBD stones, with balloon dilation for 1 min producing preferable outcomes.