Cracking Difficult Biliary Stones

Percutaneous transhepatic cholangioscopy for benign and malignant biliary disease using a novel short single-operator cholangioscope

BACKGROUND

The length of conventional single-use cholangioscopes poses a challenge for percutaneous or laparoscopic approaches for direct visualization of the biliary tract. The aim of this retrospective observational clinical study was to assess the use of a dedicated percutaneous short single-operator cholangioscope (PSSOC) for diagnosis and treatment of benign or malignant biliary diseases.

METHODS

Retrospective analysis of a prospectively maintained database including all consecutive patients undergoing percutaneous transhepatic cholangioscopy with the PSSOC between 06/2021 and 01/2023.

RESULTS

Forty patients were included (22F/18 M, age 58.7 ± 16.7 years). The diagnostic and therapeutic management plan was based on procedural findings. Indications were bile duct obstruction associated with complex anatomy (n = 13), choledocholithiasis (n = 11), suspected malignant stenosis of the biliary tract (n = 11), biliary stent placement (n = 2) and removal (n = 1), and failed endoscopic retrograde cholangiopancreatography (n = 2). The cholangioscopies were diagnostic (n = 5), therapeutic (n = 20) or both simultaneously (n = 15). The most frequent procedures were electrohydraulic lithotripsy (n = 25) and biopsy sampling (n = 12). Complications occurred in 7 cases (17.5%), including cholangitis (n = 4, B2), pleural perforation (n = 1, B2), portal bleeding (n = 1, B3), and Tako-Tsubo syndrome (n = 1, B3), classified according to the Society of Interventional Radiology classification. Intraprocedural visual diagnosis was confirmed by the histopathologic result in 11/12 patients in which biopsies were performed (91.7%). PSSOC was relevant to avoid surgery in 2 patients (5%) with indeterminate strictures, allowing to rule out malignancy and treat the lithiasis.

CONCLUSIONS

Direct visualization of the biliary tract enabled targeted biopsies for histopathological diagnosis. The visual and histopathological diagnoses were concordant in all but one case. Percutaneous cholangioscopy with a dedicated PSSOC allows to optimize identification and treatment of complex biliary disease including biliary lithiasis while assessing bile duct patency. The clinical use of the novel PSSOC system was safe and effective and could prevent surgical exploration in select patients.

Endoscopic Treatment of Large Bile Duct Stones: A Systematic Review and Network Meta-Analysis

BACKGROUND & AIMS

Several endoscopic methods have been proposed for the treatment of large biliary stones. We assessed the comparative efficacy of these treatments through a network meta-analysis.

METHODS

Nineteen randomized controlled trials (2752 patients) comparing different treatments for management of large bile stones (>10 mm) (endoscopic sphincterotomy, balloon sphincteroplasty, sphincterotomy followed by endoscopic papillary large balloon dilation [S+EPLBD], mechanical lithotripsy, single-operator cholangioscopy [SOC]) with each other were identified. Study outcomes were the success rate of stone removal and the incidence of adverse events. We performed pairwise and network meta-analysis for all treatments, and used Grading of Recommendations, Assessment, Development, and Evaluation criteria to appraise the quality of evidence.

RESULTS

All treatments except mechanical lithotripsy significantly outperformed sphincterotomy in terms of stone removal rate (risk ratio [RR], 1.03-1.29). SOC was superior to other adjunctive interventions (vs balloon sphincteroplasty [RR, 1.24; 95% CIs, 1.07-1.45], vs S+EPLBD [RR, 1.23; range, 1.06-1.42] and vs mechanical lithotripsy [RR, 1.34; range, 1.14-1.58]). Cholangioscopy ranked the highest in increasing the success rate of stone removal (surface under the cumulative ranking [SUCRA] score, 0.99) followed by S+EPLBD (SUCRA score, 0.68). SOC and S+EPLBD outperformed the other modalities when only studies reporting on stones greater than 15 mm were taken into consideration (SUCRA scores, 0.97 and 0.71, respectively). None of the assessed interventions was significantly different in terms of adverse event rate compared with endoscopic sphincterotomy or with other treatments. Post-ERCP pancreatitis and bleeding were the most frequent adverse events.

CONCLUSIONS

Among patients with large bile stones, cholangioscopy represents the most effective method, in particular in patients with larger (>15 mm) stones, whereas S+EPLBD could represent a less expensive and more widely available alternative.

Outcomes of balloon vs basket catheter for clearance of choledocholithiasis: a systematic review and meta-analysis

Background and study aims  Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay for treatment of choledocholithiasis. It is unclear whether balloon or basket catheters are better for extraction of stones ≤ 10 mm in size. We performed a meta-analysis of studies comparing rates of complete stone extraction and adverse events after ERCP using balloon vs basket catheters for bile duct stones ≤ 10 mm in size. Methods  Cochrane database, PubMed, Web of Science, and Embase were searched from inception to October 2021. Randomized control trials comparing outcomes of balloon vs basket catheter were included. Data extraction of articles was carried out by two authors using predefined inclusion criteria. Metanalysis was carried out using the Revman 5.4.1. software using a random-effects model. Results  Three studies with a total of 508 patients were included in the final analysis. For common bile duct stones ≤ 10 mm, balloon catheters had higher complete stone clearance rates than basket catheters (relative risk 1.1, confidence interval 1.03, 1.18, P  = 0.006). Heterogeneity among studies was low (Tau ²  = 0.0; P  = 0.47, I ²  = 0 %). There was no difference in the rate of complications. Conclusions  Meta-analysis of three studies indicates that balloon catheters have a higher success rate compared to basket catheters for complete stone extraction for choledocholithiasis ≤ 10 mm with no significant difference in the rate of complications.