Efficacy of spyglass-guided electrohydraulic lithotripsy in difficult bile duct stones

Post-cholecystectomy Clip Migration: A Case Report

Surgical clip migration into the common bile duct (CBD) with subsequent stone formation is an exceedingly rare complication following both laparoscopic and open cholecystectomy, with fewer than 100 cases reported in the literature. Herein, we present the case of a 78-year-old female who presented with abdominal pain and dark urine six years after an open cholecystectomy. Her abdominal ultrasonography revealed no abnormalities, with only mild derangements noted in liver function tests. However, computed tomography of the abdomen unveiled a single metallic surgical clip lodged within the CBD, surrounded by a bile stone, alongside another clip at the gallbladder fossa. The patient underwent endoscopic retrograde cholangiopancreatography (ERCP), during which the clip was successfully removed. The procedure has utilized SpyGlass cholangioscopy. While clip migration into the CBD remains a rare phenomenon, it should be considered in the differential diagnosis of patients presenting with obstructive jaundice or biliary colic post-cholecystectomy. Minimally invasive management by ERCP is the procedure of choice for migrated clips-related complications but surgical common bile duct exploration may be necessary. This case highlights the importance of vigilance and prompt intervention in managing post-cholecystectomy clip migration (PCCM) but potentially serious postoperative complications.

PREDICTORS OF FAILURE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY IN CLEARING BILE DUCT STONES DURING INDEX PROCEDURE - A PROSPECTIVE STUDY

BACKGROUND

Common bile duct (CBD) stones are known to complicate 10-15% of gallstone diseases. Endoscopic retrograde cholangiopancreatography (ERCP) is the therapeutic modality of choice for bile duct clearance in CBD stones but may fail to achieve stone clearance. This prospective study was done to identify the predictors of failure of CBD clearance with ERCP.

OBJECTIVE

This prospective study was done to identify the predictors of failure of CBD clearance with ERCP.

METHODS

All consecutive patients with bile duct stones undergoing ERCP at a tertiary care center were prospectively included from October 2020 to October 2021. The study's primary outcome was to identify and analyze factors that could predict the failure of complete CBD clearance.

RESULTS

A total of 120 patients (50.8% males, median age: 53.5 years) were included in the final analysis. Successful clearance of CBD stones during the index procedure was achieved in 70% of patients. At a cut-off stone diameter of >10.5 mm and CBD diameter of >12.5 mm, the AUC was 0.890 and 0.884, respectively, to predict failed clearance of CBD. On multivariate analysis, stone diameter ≥15 mm [odds ratio (OR) 16.97, 95% confidence interval (CI): 1.629-176.785], location of stones in hepatic ducts (OR 7.74, 95%CI: 2.041-29.332), presence of stricture distal to stone (OR 6.99, 95%CI: 1.402-34.726) and impacted stone (OR 21.61, 95%CI: 1.84-253.058) were independent predictors of failed bile duct clearance.

CONCLUSION

Stone size and location are independent predictors of failed bile duct clearance. The endoscopist should consider these factors while subjecting a patient to biliary ductal clearance to plan additional intervention.

BACKGROUND

• Failure to clear bile duct stones in the index ERCP can be seen in 15-20% of cases, and identifying the factors associated with failure is important.

BACKGROUND

• A prospective analysis was conducted to identify and analyze the factors that could predict the failure of complete CBD clearance.

BACKGROUND

• The present study reported a successful clearance of CBD stones during the index procedure in only 70% of patients.

BACKGROUND

• A stone diameter ≥15 mm, location of stones in hepatic ducts, presence of stricture distal to stone, and impacted stone were independent predictors of failed bile duct clearance.

Management of Biliary Complications in Liver Transplant Recipients

Biliary complications are often referred to as the Achilles' heel of liver transplantation (LT). The most common of these complications include strictures, and leaks. Prompt diagnosis and management is key for preservation of the transplanted organ. Unfortunately, a number of factors can lead to delays in diagnosis and make adequate treatment a challenge. Innovations in advanced endoscopic techniques have increased non-surgical options for these complications and in many cases is the preferred approach.

OUP accepted manuscript

Post-cholecystectomy clip migration with formation of bile duct stones is a known but rare complication of laparoscopic cholecystectomy. This report discusses the case of a 64-year-old lady who presented with biliary colic symptoms 12 years post laparoscopic cholecystectomy. Computed tomography of the abdomen demonstrated one surgical clip located in the distal common bile duct, with a bile stone formed around it. This was removed via ERCP with spyglass cholangioscopy and lithotripsy.

Choledochoscopy: An update

Choledochoscopy, or cholangioscopy, is an endoscopic procedure for direct visualization within the biliary tract for diagnostic or therapeutic purposes. Since its conception in 1879, many variations and improvements are made to ensure relevance in diagnosing and managing a range of intrahepatic and extrahepatic biliary pathologies. This ranges from improved visual impression and optical guided biopsies of indeterminate biliary strictures and clinically indistinguishable pathologies to therapeutic uses in stone fragmentation and other ablative therapies. Furthermore, with the evolving understanding of biliary disorders, there are significant innovative ideas and techniques to fill this void, such as nuanced instances of biliary stenting and retrieving migrated ductal stents. With this in mind, we present a review of the current advancements in choledo-choscopy with new supporting evidence that further delineates the role of choledochoscopy in various diagnostic and therapeutic interventions, complications, limitations and put forth areas for further study.

Single-operator cholangioscopy and electrohydraulic lithotripsy for the treatment of Mirizzi syndrome

INTRODUCTION

Mirizzi syndrome is an infrequent complication of long-standing cholelithiasis. Extrinsic compression of the common hepatic duct is usually caused by an impacted stone in Hartmann's pouch or cystic duct resulting in the development of cholecystobiliary fistula. This syndrome is classified based on the presence and severity of cholecystobiliary fistula. Mirizzi syndrome is challenging to diagnose preoperatively and may require complex biliary surgical procedures for resolution.

RESULTS

We present three patients with Mirizzi syndrome with different clinical presentations. All were successfully treated by cholangioscopy with electrohydraulic lithotripsy. Endoscopic treatment is a safe alternative with a high success rate. Single-operator cholangioscopy combined with lithotripsy has been shown to have a 90-100% success rate in the treatment of biliary stones.

CONCLUSION

Herein, we present our experience treating Mirizzi syndrome with single-operator cholangioscopy guided electrohydraulic lithotripsy. Difficult management of Mirizzi syndrome has led to research of new treatment options to minimize the risk of high-rate complications. Single-operator cholangioscopy in combination with laser lithotripsy is an adequate and safe alternative for the treatment of this condition.

Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis

INTRODUCTION

Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones >15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates.

AIM

To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy.

METHODS

Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies.

RESULTS

Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%).

CONCLUSIONS

For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.

Giant stentolith: A rare complication of long-dwelling biliary endoprosthesis

Endoscopic biliary stenting is performed for various indications in routine clinical practice. Plastic stents are indicated primarily for short-term biliary decompression and require removal or exchange after 12-16 weeks. However, patients who become asymptomatic after the procedure may not return for scheduled stent removal and subsequently present with severe complications. We herein present the case of a 57-year-old female who underwent biliary stenting after the endoscopic clearance of bile duct stones. Her symptoms resolved after the intervention, but she was lost to follow-up with the stent remaining in situ. Four years later, she presented with pain in the right hypochondrium and experienced recurrent episodes of cholangitis. Magnetic resonance cholangiopancreatography revealed a retained plastic stent in the proximal bile duct with a large stone cast around the stent-a stentolith. Owing to the large stone size and proximal migration of the retained biliary stent, the patient required open surgical exploration for stentolith removal. Patients with forgotten biliary stents presenting with serious complications are not uncommon in India. Unaware of the complications of long-dwelling biliary stents, patients ignore the advice for the timely removal of biliary stents. Detailed patient counselling, education and documentation are essential to avoid this condition.

Management of difficult bile duct stones and indeterminate bile duct structures: Reduced ERCP radiation exposure with adjunct use of digital single-operator cholangioscopy

INTRODUCTION

Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an well-established endoscopic procedure for the management of biliary diseases. The use of fluoroscopy during ERCP has often raised concerns regarding potential risks from radiation exposure, particularly in complex cases. We investigated whether a new digital single-operator cholangioscopy (D-SOC) system, used adjunctively to ERCP, actually reduces patient radiation exposure.

MATERIALS AND METHODS

We retrospectively analyzed a prospective database (April 2016 to October 2018) including consecutive patients who underwent successful management of difficult-to-treat biliary stones or indeterminate biliary strictures by using either conventional ERCP (ERCP cohort) or ERCP in conjunction with D-SOC (ERCP/D-SOC cohort). The overall patient radiation exposure outcomes were compared in terms of Kerma Area Product (KAP), Fluoroscopy time (T) and the total number of films (F).

RESULTS

Overall, 47 patients (mean 71.8 years, 59.6% males) were included (ERCP cohort = 29, ERCP/D-SOC cohort = 18), referred either for difficult bile duct stones (n = 36) or indeterminate biliary strictures (n = 11). The median KAP, T and F in the ERCP/D-SOC cohort were 12.3 Gycm², 3.7 min and 4 films respectively, compared with 52.1 Gycm², 8.4 min, and 5 films respectively in the ERCP cohort. Statistically significant differences (P = 0.0001) were found for KAP and T.

CONCLUSIONS

Adjunct use of a digital cholangioscopy platform appears to significantly reduce radiation exposure in patients undergoing ERCP for the management of difficult bile stones or indeterminate biliary strictures.

Single-operator peroral cholangioscope in treating difficult biliary stones: A systematic review and meta-analysis

BACKGROUND AND AIM

Current evidence supporting the utility of single-operator peroral cholangioscope (SOPOC) in the management of difficult bile duct stones is limited. We conducted the present systematic review and meta-analysis to evaluate the efficacy and safety of SOPOC in treating difficult bile duct stones.

METHODS

We searched studies up to April 2018, using MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. Quality assessment of the studies was completed with the Newcastle-Ottawa Scale. Main outcomes were complete stone clearance rate, single-session stone clearance rate, number of endoscopic sessions needed for stone clearance, and adverse events. We calculated the pooled estimates with random-effects models. Potential publication bias was assessed.

RESULTS

Twenty-four studies involving 2786 patients met the inclusion criteria. Pooled proportion of patients with complete stone clearance was 94.3% (95% confidence interval [95% CI]: 90.2-97.5%). Single-session stone clearance was achieved in 71.1% (95% CI: 62.1-79.5%) of the pooled patients. Pooled number of sessions needed for stone clearance was 1.26 (95% CI: 1.17-1.34%). Pooled adverse event rate was 6.1% (95% CI: 3.8-8.7%). Potential publication bias was detected but had no significant influence on the results.

CONCLUSIONS

Single-operator peroral cholangioscope is an effective and safe treatment for difficult bile duct stones when conventional methods have failed. More randomized controlled trials are warranted to confirm the results.

Predictors of failure of endoscopic retrograde cholangiography in clearing bile duct stone on the initial procedure

BACKGROUND/AIMS

The aim of this study is to predict cases where the clearance of the biliary system from stones at the initial endoscopic retrograde cholangiopancreatography (ERCP) might be of value for better risk-stratifying patients. We attempted to identify factors that are associated with a higher failure rate of clearing the biliary system on the index ERCP.

PATIENTS AND METHODS

This is a retrospective study from January 2008 to January 2015. All patients with bile duct stones confirmed on ERCP were included in this study. Patients who had prior attempts of bile duct stone extraction were excluded.

RESULTS

A total of 554 ERCPs were performed to extract biliary duct stones from 426 patients. The mean age was 46.3 years and 41.7% were males. The group where the index ERCP did not clear the biliary system tended to be older (50.4 vs. 45.2 years, P = 0.03). On multivariate analysis, the presence of fever (OR 4.64; 95% CI, 1.66-12.79), a larger number of filling defects (OR 1.34; 95% CI, 1.13-1.93), presence of a stricture distal to a stone (OR 4.63; 95% CI, 1.36-15.78), the use of an extraction basket (OR 3.23; 95% CI, 1.56-6.74), and/or mechanical lithotripsy (OR 3.05; 95% CI, 1.10-8.49) were all associated with a lower odds of clearing the biliary system. The use of an extraction balloon was associated with the success of clearing the biliary system (99.7% vs. 77.4%, P < 0.01) and a lower odds of failing (OR 0.01; 95% CI, 0.00-0.08) on multivariate analysis.

CONCLUSION

A few of the characteristics that are found on cholangiography at the index ERCP could be used to identify patients that might require more than one ERCP to clear the biliary system from stones.

Safety and efficacy of SpyGlass cholangiopancreatoscopy in routine clinical practice in a regional Singapore hospital

INTRODUCTION

This study examined the efficacy and safety of cholangiopancreatoscopy via the SpyGlass™ system in routine clinical practice.

METHODS

The clinical data of endoscopic retrograde cholangiopancreatography (ERCP) performed in a regional hospital from January 2013 to November 2016 was retrieved from an electronic database and reviewed. All patients who had undergone SpyGlass cholangiopancreatoscopy were enrolled. Patient demographics, procedure indication, technical success rates, clinical success rates and complication rates were analysed. A subanalysis of clinical outcomes was performed comparing the SpyGlass legacy (fibreoptic) and digital systems.

RESULTS

Out of 2,050 ERCP procedures performed, 47 patients underwent 50 cholangiopancreatoscopy procedures. Clinical indications were difficult common bile duct (CBD) stones (59.6%, n = 28), indeterminate CBD stricture (36.2%, n = 17), indeterminate pancreatic duct stricture (2.1%, n = 1) and proximally migrated CBD stent (2.1%, n = 1). Complete stone extraction was achieved in 26 (92.9%) out of 28 patients. Among patients with strictures, a correct diagnosis of malignancy based on image visualisation was achieved in all 11 cases. The sensitivity and specificity for SpyBite™ biopsies were 81.8% (95% confidence interval [CI] 48.2%-97.7%) and 100.0% (95% CI 15.8%-100.0%), respectively. The proximally migrated CBD stent was successfully extracted. Complications included pancreatitis (2.1%, n = 1), suspected sealed perforation after laser lithotripsy treated conservatively (2.1%, n = 1) and cholangitis (10.6%, n = 5). There was no difference in clinical outcomes between the SpyGlass legacy (n = 20) and digital (n = 30) systems.

CONCLUSION

SpyGlass cholangiopancreatoscopy is a safe and effective tool in routine clinical practice.

Biliary and pancreatic lithotripsy devices

BACKGROUND AND AIMS

Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL).

METHODS

In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations.

RESULTS

Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs.

CONCLUSIONS

Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Randomized study of digital single-operator cholangioscope compared to fiberoptic single-operator cholangioscope in a novel cholangioscopy bench model

BACKGROUND AND STUDY AIMS

 Cholangiopancreatoscopy is utilized for diagnosis and therapy of pancreaticobiliary disorders. a fully-disposable, digital, single-operator cholangioscope (DSOC) was developed with high image resolution and wide field-of-view. This bench study compared the new DSOC to the previous semi-disposable, fiber-optic cholangioscope (FSOC) prior to the clinical availability of the DSOC system.

METHODS

Five experts performed one practice run followed by randomized runs comparing DSOC to FSOC in a biliary tract model consisting of three fixed left-intrahepatic tracts (LIHD), and variable common bile duct (CBD) and right-intrahepatic tracts (RIHD) with seven total lesions in multiple configurations. Timed runs aimed to visualize and target each lesion using miniature biopsy forceps. Definitions: visual success, visualizing targets; targeting success, touching target with forceps; complete run, touching seven targets within 20 minutes. Image quality, ease-of-use, and time to completion were recorded.

RESULTS

Thirty-seven evaluable runs (20 DSOC, 17 FSOC) were completed. DSOC was superior to FSOC in Visual (99 % vs. 67 %, P  < 0.001) and targeting success (6.6 vs. 4.5, P  = 0.009), proportion of complete runs (13 /20 vs. 0 /17, P  < 0.001) and time of run (10.1 min vs. 15.4 min, P  < 0.001). For fixed LIHD, DSOC achieved higher targeting success compared to FSOC (2.6 vs. 1.1, P  < 0.001) with no difference in RIHD and CBD targets (4.0 vs. 3.4, P  = 0.39). Investigators reported superior image quality and ease-of-use with DSOC.

CONCLUSIONS

In this model, DSOC performed superiorly to FSOC in image quality, visualization, and maneuverability. The model could potentially be utilized for training endoscopists less experienced with cholangiopancreatoscopy.

Pancreatoscopy-Directed Electrohydraulic Lithotripsy for Pancreatic Ductal Stones in Painful Chronic Pancreatitis Using SpyGlass

OBJECTIVE

Painful chronic pancreatitis is often associated with main duct obstruction due to stones. Approaches to management are challenging, including surgery, extracorporeal shock wave lithotripsy, or endoscopic approaches. Here, we report our experience of pancreatoscopy + electrohydraulic lithotripsy (EHL) for pancreatic duct (PD) stones using SpyGlass.

METHODS

We retrospectively audited the use of SpyGlass (Legacy and DS) + EHL. Indication, procedural details, and clinical outcomes were assessed.

RESULTS

A total of 118 SpyGlass + EHL procedures for stones were performed, of which 8 (7%) for pancreatic stones, in 6 patients (3 female; mean [standard deviation] age, 45 [7] years). All patients had painful chronic pancreatitis, with radiological evidence of a dilated PD, and main duct stone disease. Surgical options had been considered in all cases. Stone fragmentation and PD decompression were achieved in 83% (n = 5) without complications. Two patients required 2 EHL procedures to achieve clearance. In 1 patient with failed clearance, pancreatoscopy revealed a stone in the adjacent parenchyma and not in PD. All patients with successful EHL had pain relief/marked improvement at clinical review (mean [standard deviation] follow-up, 2.7 [1.1] years).

CONCLUSIONS

Pancreatoscopy + EHL may have a valuable role in treating obstructing PD stones, possibly avoiding the need for surgery in some patients.

Single-Operator Peroral Cholangioscopy for Extraction of Cystic Duct Stones in Postcholecystectomy Mirizzi Syndrome

Mirizzi syndrome is an exceptionally rare diagnosis with an annual incidence of less than 1% in developed countries. In this disease process, stone burden in the cystic duct or gallbladder neck leads to common hepatic duct obstruction, either by mechanical compression or secondary inflammation. Mirizzi syndrome is classified into one of four types based on the presence and severity of cholecystobiliary fistulization. Treatment is primarily surgical in nature and largely dictated by the type of Mirizzi syndrome encountered. It is typically diagnosed in the preoperative or operative setting of cholecystectomy; however, there have been rare occurrences of postcholecystectomy diagnosis. Factors thought to predispose to postcholecystectomy disease include low insertion of the cystic duct and long remnant duct length. Few case reports exist describing this phenomenon and its management, which is made exceptionally difficult due to the presence of inflammation and surgical adhesion. We present the case of a young female with postcholecystectomy Mirizzi syndrome who underwent successful endoscopic management using peroral cholangioscopy and electrohydraulic lithotripsy. We also provide a brief overview of both Mirizzi syndrome and peroral cholangioscopy.

Usefulness of the single-operator cholangioscopy system SpyGlass in biliary disease: a single-center prospective cohort study and aggregated review

BACKGROUND AND STUDY AIM

Indeterminate biliary strictures and difficult bile duct stones remain clinically arduous and challenging situations. We aimed to evaluate the utility of the single-operator cholangioscopy (SOC)-system SpyGlass in both conditions in a single-center biliopancreatic interventional unit and in perspective of available aggregated literature.

METHODS

Usefulness of SOC was assessed for the above-mentioned indications by means of the combination of successful procedural completion, clinical success and incidence of procedure-related adverse events in our own prospective cohort from 3/2010 to 7/2014 and all available literature till 6/2015.

RESULTS

Our single-center cohort constituted of 84 patients undergoing SpyGlass either for indeterminate strictures (n = 45) or difficult stones (n = 39). In addition, a comprehensive literature review yielded 851 patients (from 15 series) for either stenosis (n = 646, 75.9 %) and difficult stones (n = 205, 24.1 %). In our series, overall procedural success amounted to 85.7 % (with 88.9 % for stenosis or 82.1 % for stones) compared to 90.7, 91.5 and 88.3 % in overall literature, respectively. Sensitivity, specificity and accuracy for visual diagnosis in our cohort added up to 83.3, 82.9 and 82.9 % compared to 90.8, 90.9 and 90.8 % in the pooled analysis. Respective figures for SOC-directed biopsies totaled 85.7, 100 and 95.7 % in our cohort and 72.4, 100 and 84 % overall. Overall procedure-related complications varied between 9.4 and 21.4 %.

CONCLUSIONS

The SOC-platform SpyGlass can be considered useful in the context of indeterminate biliary strictures and difficult-to-remove biliary stones. In both, SpyGlass-assisted intervention is associated with high procedural success and alters clinical outcome compared to conventional approaches with an acceptable safety profile.