Bile-Duct Stone Removal under Direct Transnasal Cholangioscopy Using an Ultraslim Upper Endoscope

Direct biliary drainage using transnasal endoscopy for patients with severe-to-moderate acute cholangitis

BACKGROUND AND AIM

Endoscopic biliary drainage (BD) is an effective palliative treatment for acute cholangitis. Transnasal endoscopy (TNE) using an ultraslim endoscope can be less stressful and has limited hemodynamic effects compared with endoscopic retrograde cholangiography using a conventional duodenoscope. Here, we evaluate the clinical usefulness of direct BD by TNE in critically ill patients with acute cholangitis who had undergone endoscopic sphincterotomy (ES) previously.

METHODS

Twenty-three patients with severe-to-moderate acute cholangitis who had undergone ES previously were enrolled prospectively. BD was achieved by TNE, using an ultraslim upper endoscope with a 5-Fr nasobiliary drainage catheter and/or a plastic stent. The technical and clinical success, as well as the safety, of the procedure were investigated.

RESULTS

A total of 23 patients were enrolled, including 17 with bile duct stones. The severity of the cholangitis was severe in nine (39.1%) and moderate in 14 patients (60.9%). The technical success rate was 95.7% (22/23). Nasobiliary drainage was performed in 15 patients, a plastic stent was placed in three, and both treatments were used in four patients. In three patients, direct BD by TNE was achieved in the intensive care unit without fluoroscopy. Direct cholangioscopy for distal common bile duct was performed in nine patients (40.9%), and three patients underwent immediate stone extraction under endoscopic visualization. Clinical improvement was achieved in 20/23 (87.0%) of patients. No significant procedure-related complications occurred.

CONCLUSION

Direct BD by TNE may be useful in critically ill patients with severe-to-moderate acute cholangitis who had undergone ES previously.

Endoscopic management of difficult common bile duct stones

Endoscopy is widely accepted as the first treatment option in the management of bile duct stones. In this review we focus on the alternative endoscopic modalities for the management of difficult common bile duct stones. Most biliary stones can be removed with an extraction balloon, extraction basket or mechanical lithotripsy after endoscopic sphincterotomy. Endoscopic papillary balloon dilation with or without endoscopic sphincterotomy or mechanical lithotripsy has been shown to be effective for management of difficult to remove bile duct stones in selected patients. Ductal clearance can be safely achieved with peroral cholangioscopy guided laser or electrohydraulic lithotripsy in most cases where other endoscopic treatment modalities have failed. Biliary stenting may be an alternative treatment option for frail and elderly patients or those with serious co morbidities.

Holmium laser lithotripsy under direct peroral cholangioscopy by using an ultra-slim upper endoscope for patients with retained bile duct stones (with video)

BACKGROUND

Direct peroral cholangioscopy (POC) by using an ultra-slim endoscope provides direct visualization of the bile duct and allows for therapeutic intervention. Holmium laser lithotripsy can be effective for retained bile duct stones, but it requires direct visualization during the procedure for safe and effective fragmentation. Direct POC by using an ultra-slim endoscope may facilitate holmium laser lithotripsy.

OBJECTIVE

To evaluate the feasibility, success rates, and complications of holmium laser lithotripsy under direct POC by using an ultra-slim endoscope for retained bile duct stones.

DESIGN

Observational clinical feasibility study.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved 13 patients with retained bile duct stones whose treatment failed by a conventional lithotripsy method involving mechanical lithotripsy.

INTERVENTION

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope.

MAIN OUTCOME MEASUREMENTS

Success rate of complete stone removal and procedure-related complications.

RESULTS

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was successful in 11 of 13 patients (84.6%). Although direct POC was successful, holmium laser lithotripsy failed in 2 patients because of inaccurate targeting of the laser fiber to stones. There were no procedure-related complications except one case of mild pancreatitis.

LIMITATIONS

A small number of patients and no comparison with other lithotripsy systems.

CONCLUSION

Holmium laser lithotripsy under direct POC by using an ultra-slim endoscope was feasible and can be a safe endoscopic management method for retained bile duct stones.