Sonographic features of Lemmel's syndrome: Differential diagnosis from stones in the lower portion of the common bile duct

BACKGROUND AND STUDY AIMS

Periampullary diverticula (PAD), a location-specific type of duodenal diverticula, can cause serious complications. PAD is difficult to differentially diagnose, mainly due to its nonspecific symptoms. This study aimed to identify sonographic features of PAD and to evaluate their value in the differential diagnosis of PAD from stones in the lower common bile duct (CBD).

PATIENTS AND METHODS

A total of 30 patients with PAD and 60 patients with lower CBD stones were retrospectively enrolled, and sonographic features were analyzed. Measurements of sonographic features included echo shaped, posterior echo changes, location and relation to surrounding organs, and status of intrahepatic and extrahepatic bile duct dilation, and their diagnostic performance was assessed.

RESULTS

Characteristic sonographic features of PAD were identified, including strong echoes (28/30, 93.3 %), strip shape (28/30, 93.3 %), multiple reflections in the posterior echo (27/30, 90.0 %), and location outside the CBD or near the biliary wall in connection with the duodenum (27/30, 90.0 %). Inter-observer agreement was good (Kappa values = 0.69-0.82). Comparative analysis of sonographic features revealed significant differences in echo shape, posterior echo changes (multiple reflections and acoustic shadowing), location and relation to surrounding organs, and intrahepatic and extrahepatic bile duct dilatation status between the dilatation status of the two groups. In particular, these characteristics achieved a sensitivity of 100 % and a specificity of 98 % for the differential diagnosis of PAD and lower CBD stones.

CONCLUSIONS

This study identified characteristic sonographic features of PAD, which could be used as potential diagnostic indicators to distinguish PAD from lower CBD stones.

Orlando protocol for single session ductal clearance of common bile duct stones at ERCP

OBJECTIVES

Approach to management of common bile duct stones (CBDS) by endoscopic retrograde cholangiopancreatography (ERCP) is not standardized. We examined outcomes by applying predetermined protocol for CBDS management.

METHODS

When standard extraction techniques failed at ERCP, presence of tapered bile duct and stone-duct ratio were calculated. Large balloon sphincteroplasty (LBS) and/or mechanical (ML)/single-operator cholangioscopy-guided lithotripsy (SOCL) was performed based on presence of tapered bile duct and stone-duct mismatch. Primary outcome was single-session ductal clearance. Secondary outcome was adverse events.

RESULTS

Of 409 patients treated over 16 months, 321 (78.5%) had no tapered bile duct or stone-duct mismatch and single-session ductal clearance was achieved using standard techniques in 99.7% over median duration of 14 minutes (IQR 9-21 mins). Of 88 (21.5%) patients with difficult CBDS, tapered duct was seen in 79 (89.8%) and/or stone-duct mismatch in 36 (40.9%). Single-session ductal clearance was achieved in all 88 patients (100%) by LBS in 79 (89.8%), ML in 20 (22.7%) and SOCL in 16 (18.2%) over median duration of 29 minutes (IQR 17-47 mins). Overall, single-session ductal clearance was achieved in 99.8% with adverse events in 17 (4.2%) that included perforation in 2, post-sphincterotomy bleeding in 1, and mild/moderate post-ERCP pancreatitis in 14 patients.

CONCLUSIONS

A predetermined protocol optimized outcomes by enabling single-session ductal clearance of CBDS with high technical success and low adverse events.

The "Basket-in-Catheter" technique: facilitating transcystic bile duct exploration and optimising the management of suspected ductal stones

The 'Basket-in-Catheter' (BIC) technique facilitates basket-only laparoscopic transcystic exploration (LTCE), increasing its success rate. Using the cholangiography catheter as a sheath is easier and safer than inserting the wire basket-alone. This study evaluates its benefits in confirmed and suspected ductal stones. Retrospective analysis of prospectively collected data on patients with pre-operative or operative suspicion of bile duct stones or with positive and equivocal intraoperative cholangiographies (IOC) who had LTCE attempted using blind basket trawling, without choledochoscopy, were reviewed. The incidence and outcomes of blind basket LTCEs attempted before and after introducing the BIC technique, whether or not stones were retrieved, were analysed. Blind basket LTCE was attempted in 732 patients. Of 377 (51.5%) patients undergoing successful stone retrieval, only 62% had pre-operative clinical and radiological risk factors for ductal stones, 25% had operative risk factors and 13% had silent stones discovered on IOC. Another 355 patients (48.5%) had negative trawling, although one half had pre-operative risk factors for ductal stones and 47.6% had operative risk factors, e.g. cystic duct stones or dilatation. This cohort had equivocal cholangiography in 25.9%. Following basket trawling, repeat IOC confirmed resolution of abnormalities. As no stones were retrieved, these were not considered duct explorations. The BIC technique facilitates safe and speedy bile duct clearance when stones are confirmed, avoiding choledochotomies, without significant complications. BIC duct trawling is also beneficial in patients with suspected ductal stones, helping to resolve equivocal IOCs. It helps surgeons to acquire and consolidate ductal exploration skills.

One-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiography bile duct stone extraction is a feasible option in Indonesia within the National Health Insurance System

INTRODUCTION AND IMPORTANCE

Bile duct stones are a widespread condition that can pose a significant risk to life due to the occurrence of complications. In recent years, there has been a growing inclination toward the use of one-stage minimally invasive procedures for the treatment of this condition. However, it is important to note that in developing countries, such as Indonesia, where the National Healthcare Insurance System is established, the implementation of these procedures is still relatively uncommon due to limitations in healthcare facilities.

CASE PRESENTATION

This study presents a case series involving 13 patients who underwent a consecutive initial attempt of one-stage Laparoscopic Cholecystectomy with subsequent Intraoperative Endoscopic Retrograde Cholangiopancreatography (LC-ERCP) for the extraction of bile duct stones. These patients were among the 124 individuals treated for bile duct stones at our hospital for one year (June 2022 to May 2023). All the participants in this study were covered by the National Health Insurance.

CLINICAL DISCUSSION

Among the 124 patients diagnosed with bile duct stones, thirteen (10.5 %) were subjected to an initial attempt of one-stage LC-ERCP procedure, which had a success rate of 76.4 %. However, three of them experienced difficulties during the cannulation of bile duct, leading to the failure of this approach. The patients included in the study had a mean age of 46.5 years, with average serum levels of total bilirubin and direct bilirubin measuring 2.1 and 1.4 mg/dL, respectively. The average duration of successful and unsuccessful procedures was 121.5 min and 183.3 min, respectively. The average length of postoperative hospital stay was 3.5 days, and no instances of mortality or complications were recorded during the study.

CONCLUSION

One-stage LC-ERCP procedure offered a promising treatment option for bile duct stones in Indonesia, particularly for patients registered under the National Healthcare Insurance System. This approach could serve as a viable alternative for facilities that lack proficiency in LC-CBDE skills. Furthermore, the ability to perform ERCP in a supine position is crucial in achieving a high success rate. The results of this study showed the need for advancements in Indonesian public healthcare facilities to meet the growing demand for improved treatment modalities.

Distal Biliary Stent Migration in Patients with Irretrievable Bile Duct Stones: Long-Term Comparison Between Straight and Double-Pigtail Stents

BACKGROUND

Prolonged biliary stenting may be considered in high-risk patients with irretrievable bile duct stones (IBDS). Distal stent migration (DSM) is a known complication, although data beyond the recommended interval of temporary stenting (3-6 months) are lacking. We compared the long-term incidence of DSM between straight and double-pigtail stents in patients with IBDS.

METHODS

Consecutive patients with IBDS undergoing plastic biliary stenting (1/2009-12/2019) were retrospectively reviewed. DSM was confirmed on follow-up examination when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Kaplan-Meier and Cox regression analyses were used to determine estimates and predictors of DSM.

RESULTS

Overall, 618 biliary stenting procedures (410 patients) were included: 289 with a straight stent (group A) and 329 with a double-pigtail (group B). By Kaplan-Meier analysis, the DSM rates were 8.4 and 14.6% at 6 months, 21.4 and 27.7% at 12 months, 27 and 43.5% at 18 months, and 37.2 and 60.4% at 24 months, for groups A and B, respectively (p = 0.004). Double-pigtail stents were at higher risk for DSM (HR = 7.38, p = 0.04), whereas an inverse correlation was noted with age (HR = 0.97, p = 0.0001). Considering only temporary stenting procedures (≤ 6 months; n = 297), the probability of DSM was not significantly different between the two groups (p = 0.07).

CONCLUSIONS

In a setting of prolonged stenting for IBDS, the probability of DSM appears to be higher when a double-pigtail stent is used and in younger patients. A relative anti-migratory advantage of double-pigtail over straight stents appears negligible in this study.

Future of Cholangioscopy

This article highlights the current status of cholangioscopy. In addition, the authors present their view on the future directions of cholangioscopy, including novel clinical applications, the need for technologic developments, and the expansion on the use of cholangioscopy in clinical practice. The authors envision that cholangioscopy will eventually become a conventional tool in the shelf of any biliary endoscopist. Future technologic improvements including optics, maneuverability, and full device accessories, plus the introduction of real-time artificial intelligence algorithms, will optimize the outcomes of cholangioscopy, but baseline proficiency in therapeutic endoscopic retrograde cholangiopancreatography will remain necessary for its successful utilization.

Intraoperative cholangiography 2020: Quo vadis? A systematic review of the literature

BACKGROUND

There are few randomized controlled trials with sufficient statistical power to assess the effectiveness of intraoperative cholangiography (IOC) in the detection and treatment of common bile duct injury (BDI) or retained stones during cholecystectomy. The best evidence so far regarding IOC and reduced morbidity related to BDI and retained common bile duct stones was derived from large population-based cohort studies. Population-based studies also have the advantage of reflecting the outcome of the procedure as it is practiced in the community at large. However, the outcomes of these population-based studies are conflicting.

DATA SOURCES

A systematic literature search was conducted in 2020 to search for articles that contained the terms "bile duct injury", "critical view of safety", "bile duct imaging" or "retained stones" in combination with IOC. All identified references were screened to select population-based studies and observational studies from large centers where socioeconomic or geographical selections were assumed not to cause selection bias.

RESULTS

The search revealed 273 references. A total of 30 articles fulfilled the criteria for a large observational study with minimal risk for selection bias. The majority suggested that IOC reduces morbidity associated with BDI and retained common bile duct stones. In the short term, IOC increases the cost of surgery. However, this is offset by reduced costs in the long run since BDI or retained stones detected during surgery are managed immediately.

CONCLUSIONS

IOC reduces morbidity associated with BDI and retained common bile duct stones. The reports reviewed are derived from large, unselected populations, thereby providing a high external validity. However, more studies on routine and selective IOC with well-defined outcome measures and sufficient statistical power are needed.

Best evidence topic: Should patients with asymptomatic choledocholithiasis be treated differently from those with symptomatic or complicated disease?

Choledocholithiasis is a common finding in clinical practice, with presentation varying from asymptomatic to life-threatening complications. In symptomatic patients, there is no doubt that treatment to clear the bile duct is indicated, but there is still a debate regarding the treatment of patients with silent common bile duct stones (CBDS). The question addressed by this best evidence topic is whether patients with asymptomatic CBDS should be managed in the same way as patients with symptoms or complications. The search strategy yielded 609 articles, from which 8 articles found to be relevant to this topic. We also summarised the most notable societal guidelines recommendations, regarding this topic. We tabulated the article title, author, year, country, study type, outcomes, results, and comments. We concluded that patients with asymptomatic CBD stones should be offered endoscopic treatment If they are fit, after discussion of the potential risks and benefits of both options of conservative and interventional treatment with the patients.

Pancreatic duct guidewire placement for biliary cannulation as a risk factor for stone residue after endoscopic transpapillary stone removal

Background

Recent improvements in stone extraction implements and apparatus have lessened the complexity of the endoscopic bile duct stone treatment. However, despite confirmation of complete removal, cases of residual stones have been reported, which can result in recurrent biliary symptoms, cholangitis, and pancreatitis and considerably increase cost given the need for repeat imaging and/or procedures. To date, risk factors for residual bile duct stones following endoscopic retrograde cholangiopancreatography (ERCP) extraction have not been thoroughly evaluated. This study retrospectively investigated the incidence and risk factors of residual bile duct stones following extraction via ERCP.

Methods

We retrospectively reviewed all ERCP cases that underwent endoscopic bile duct stone extraction between April 2014 and March 2019. A total of 505 patients were enrolled and evaluated for the incidence and risk factors of residual bile duct stones after ERCP.

Results

The rate of residual stones was 4.8% (24/505). Residual stones were detected by computed tomography (12/24) or magnetic resonance cholangiopancreatography (12/24). In univariate analyses, a large number of stones (P = 0.01), long procedure time (P = 0.005), and performance of the pancreatic duct guidewire placement method (P-GW) for selective bile duct cannulation (P = 0.01) were the factors involved in residual stones. In multiple logistic regression analysis, performing P-GW was retained as the only independent factor of residual stones (adjusted odds ratio, 3.44; 95% CI, 1.19–9.88; P = 0.02).

Conclusions

When removing bile duct stones with a pancreatic guidewire in place, paying attention to residual stones is necessary.

The location of bile duct stones may affect intra- and postoperative cholecystectomy outcome: A population-based registry study

BACKGROUND

Treatment for bile duct stones (BDS) depends largely on anatomical circumstances; yet, whether the outcome of cholecystectomies is impacted by the localization of intraoperatively discovered BDS remains largely unknown.

METHODS

A population-based registry study using data from the national Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). 115,084 cholecystectomies 2006-2016 with the indications gallstone colic or complications were included. The surgical outcome between patients with distal BDS and those with at least one stone above the confluence was compared.

RESULTS

10,704 met the inclusion criteria. Patients with stones above the confluence had 16% longer operation times and significantly higher rates of intraoperative complications (OR 1.47), gut perforation (OR 4.60), and cholangitis (OR 1.96) compared to patients with distal BDS. The highest clearance rate (96%), as reflected by the need for re-ERCP, was seen after intraoperative ERCP, regardless of the localization of the BDS.

CONCLUSIONS

Stones located above the confluence are associated with increased complication risks. These findings stress the importance of carefully considering the optimal methods for BDS removal during surgery.

Risk Factors for Success, Complications, and Death after Endoscopic Sphincterotomy for Bile Duct Stones: A 17-Year Experience with 2,137 Cases

BACKGROUND

Risk factors for post-endoscopic retrograde cholangiopancreatography (ERCP) complications are well-studied. However, risk factors for complications and success after endoscopic sphincterotomy (EST) for duct stones are poorly determined. This study aimed to verify risk factors for mortality, complications, and success after EST.

METHODS

A multivariate analysis was carried out in a dataset of ERCPs performed during 17 years.

RESULTS

A total of5,226 ERCPs were performed, of which 2,137 were in patients with bile duct stones (1,458 women and 679 men; mean age = 57 years) who underwent EST with attempted stone removal. There were 171 (8%) complications, with pancreatitis in 87 (4.1%), bleeding in 48 (2.2%), other complications in 36 (1.8%), and mortality of 0.6%. Successful stone(s) removal was obtained in 2,028 cases (94.9%). On multivariate analysis, mortality was associated with age >60 years (1 vs. 0.2%), cholangitis (4.3 vs. 0.3%), and EST-related complications (5.8 vs. 0.2%). Complications were associated with unsuccessful stone removal (13.4 vs. 7.5%) and difficult cannulation (13.9 vs. 5.4%). An unsuccessful EST was independently related to difficult cannulation (86.2 vs. 98.7%), precutting (79.4 vs. 96.4%), and complications (86.5 vs. 95.6%).

CONCLUSIONS

Risk factors for complications after EST for stones are delayed bile duct cannulation and failed stone retrieval. Mortality is higher in older patients, those who presented with an EST-related complication, or those who presented initially with cholangitis. Difficult cannulation, EST-related complications, and precutting were associated with an unsuccessful procedure. In this series, outpatient EST with attempted stone retrieval was found to be as safe as performing the procedure in hospitalized patients.

Management of bile duct stones at cholecystectomy: an Australian single-centre experience over 2 years

BACKGROUND

Bile duct stones with an intact gallbladder can be treated with either bile duct exploration at cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) before or after cholecystectomy. The aim of this study was to evaluate the management of bile duct stones at cholecystectomy at our institution. We also aimed to identify risk factors for failure of ductal clearance in our series.

METHODS

A retrospective review of 690 laparoscopic cholecystectomies over a 2-year period was performed. Patients who underwent laparoscopic bile duct exploration formed the study population.

RESULTS

Of 69 patients with suspected bile duct stones at cholecystectomy 67 (97%) patients underwent laparoscopic bile duct exploration upfront. Complete ductal clearance was achieved in 52 (78%) patients. Postoperative complications (10/67, 15%) included postoperative bleeding (2/67, 3%), bile leak (1/67, 1%), and superficial wound infection (1/67, 1%). There was no mortality. The mean operative time was 126 min and the median length of stay was 2 (1-4) days. A wider common bile duct (CBD) (≥ 8 mm) increased the risk of failed ductal clearance (OR 4.50; 95% confidence interval (CI) 1.15-19.23).

CONCLUSION

This study found that laparoscopic bile duct exploration can effectively and safely treat bile duct stones suspected at cholecystectomy.

Choledochal cyst mimicker-When small bowel length matters

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The diagnosis and treatment of choledochal cysts (and conditions mimicking choledochal cysts) may prove difficult in patients with short bowel syndrome.

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Laparoscopic bile duct excision and reconstruction is a feasible and safe approach to bile duct excision in experienced hands.

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Hepatico-duodenostomy should be considered a safe alternative for biliary reconstruction in individuals with limited material for conduit.

Objective

Due to the risk of malignancy, the established management of choledochal cysts mandates bile duct excision and biliary reconstruction. While the reconstructive procedure of choice for most surgeons has traditionally been hepatico-jejunostomy, this may not be feasible in selected cases due to immobility or inadequacy of the jejunum. The following case will outline the management of a 32-year-old woman with short bowel syndrome, who was diagnosed with choledocholithiasis and a type 1 choledochal cyst.

Method and materials

As a child, our patient suffered midgut volvulus secondary to malrotation which resulted in extensive bowel resection and developed short bowel syndrome. She presented with recurrent bouts of cholangitis. Imaging of her biliary tree confirmed common duct stones extending into the branched hepatic ducts, as well as a fusiform dilatation of the common bile duct, that appeared consistent with a type 1 choledochal cyst. Laparoscopic excision of the cyst with reconstruction using a hepatico-duodenostomy was planned.

Results

The patient underwent successful laparoscopic cholecystectomy, CBD clearance with excision of the bile duct and reconstruction with hepatico-duodenostomy. Recovery was uneventful and she is asymptomatic on subsequent follow-up. Histology is consistent with a markedly dilated bile duct rather than a choledochal cyst.

Conclusions

This case illustrates the dilemma of diagnosis and treatment of a dilated bile duct mimicking a choledochal cyst in the setting of short bowel syndrome and the feasibility of a laparoscopic approach in such cases. Also, it demonstrates that hepatico-duodenostomy may be a safe alternative in cases with limited material for conduit.

An investigation into the sensitivity of endoscopic ultrasound in the diagnosis of malignant bile duct in patients with idiopathic acute pancreatitis

Introduction and Objective

Acute pancreatitis (AP) is an inflammatory process of the pancreas characterized by abdominal pain and increased pancreatic enzymes. This disease is diagnosed clinically. Endoscopic ultrasound (EUS), which is a technique with high sensitivity and specificity, is used to diagnose biliary disease. This study aimed to determine the sensitivity of EUS in the diagnosis of malignant bile duct in patients with idiopathic AP.

Methods

This descriptive study was performed on 146 patients with pancreatitis hospitalized in the gastrointestinal tract section of the Imam Khomeini Hospital of Ahwaz Jundishapur University of Medical Sciences. The collected data were analyzed by the SPSS 22.0 and the significance level of the test was <0.05.

Results

According to the results, 79 (54%) out of the 146 patients were female and 67 (46%) were male. The mean and standard deviation of the patients' age were 52.5 and 19.6 years, respectively. The findings showed that the sensitivity and specificity of the EUS were 33% and 99%, respectively. Compared to the endoscopic retrograde cholangiopancreatography (ERCP), the sensitivity and specificity of the abdominal ultrasound were 62% and 62.5%, respectively. Compared to the ERCP, the sensitivity and specificity of EUS were 92% and 50%, respectively.

Conclusion

The findings of this study showed that the sensitivity and specificity of EUS were higher than those of abdominal ultrasound. Moreover, EUS was the preferred method to detect common bile duct stones (CBDS).

Endoscopic Papillary Large Balloon Dilation Versus Endoscopic Sphincterotomy for Treatment of Bile Duct Stones

PURPOSE OF REVIEW

To review the current literature focusing on the indications, efficacy, and safety of endoscopic papillary balloon dilation (EPBD) and endoscopic papillary large balloon dilation (EPLBD) with or without endoscopic sphincterotomy (EST) in the treatment of bile duct stones. • EPBD without EST is associated with a higher risk of post-procedural pancreatitis and lower rate of stone clearance than EST alone. • EPBD without EST should be at least 2 min in duration, and placement of a pancreatic stent and other measures to reduce pancreatitis risk should be considered. • EPBD without EST is most useful to reduce risk of bleeding in patients with coagulopathy. • EPLBD combined with EST can be used as an alternative or adjunct to mechanical lithotripsy in the removal of large or difficult bile duct stones. • EPLBD combined with EST results in fewer complications than EST alone for removal of bile duct stones.

Analysis of Wire-Guided Hemostasis Introducer for Percutaneous Therapy of Bile Duct Stones

BACKGROUND

Bile duct stones (BDS) are usually removed via endoscopic retrograde cholangiopancreatography (ERCP) or, if ERCP remains unsuccessful, percutaneous transhepatic cholangiodrainage (PTCD). However, PTCD provides limited access to large BDSs. We analyzed a modified approach of PTCD for percutaneous therapy of BDS.

METHODS

We used a modified approach of PTCD with a 13-french (Fr) hemostasis introducer for transhepatic access to BDS. Short-wired balloon or basket catheter were applied for safe removal of BDS. Patient characteristics, effectiveness, and complications were analyzed.

RESULTS

We identified 11 patients who underwent PTCD with hemostasis introducer. BDSs were either pushed forward to the duodenum (36%) or both partly pushed and extracted via hemostasis introducer (64%). In some cases, mechanical lithotripsy was necessary (45%). Complete removal of BDS was initially achieved in 36% of patients, 45% received additional PTCD, and in 19% stent implantation was performed. Finally, all BDSs could be removed. Laboratory analysis revealed significant reduction of alkaline phosphatase (p = 0.03) and C reactive protein (p = 0.03). Complications occurred only in 1 patient with post-interventional cholangitis.

CONCLUSION

Our study showed feasibility and safety of a modified PTCD with hemostasis introducer. In addition, protection of liver tissue from sharp-edged catheters and stones was achieved. Therefore, our modification revealed an innovational approach for transhepatic removal of BDS.

Endoscopic Management of Difficult Bile Duct Stones

PURPOSE OF REVIEW

In 10-15% of the cases, conventional methods for removing bile duct stones by ERCP/balloon-basket extraction fail. The purpose of this review is to describe endoscopic techniques in managing these "difficult bile duct stones."

RECENT FINDINGS

Endoscopic papillary large balloon dilation with balloon extraction ± mechanical lithotripsy is the initial approach used to retrieve large bile duct stones. With advent of digital cholangioscopy, electrohydraulic and laser lithotripsy are gaining popularity. Enteroscopy-assisted or laparoscopic-assisted approaches can be used for those with gastric bypass anatomy. Difficulties in removing bile duct stones can be related to stone-related factors such as the size and location of the stone or to altered anatomy such as stricture in the bile duct or Roux-en-Y anatomy. Several endoscopy approaches and techniques have described in the recent past that have greatly enhanced our ability to remove these "difficult" bile duct stones.

One-stage laproendoscopic procedure versus two-stage procedure in the management for gallstone disease and biliary duct calculi: a systemic review and meta-analysis

BACKGROUND

Laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography (ERCP) are secure and effective techniques that recently been used to treat bile duct stones. The purpose of this research was to assess the intra-procedural efficacy and postprocedural upshots of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE) and ERCP plus laparoscopic cholecystectomy (ERCP + LC).

METHODS

All studies contrasting one-stage (LCBDE) with two-stage (ERCP/EST + LC) managements in patients with concomitant gallstones and common bile duct (CBD) stones were included. The primary outcomes were CBD stone clearance, postoperative morbidity, and mortality, while secondary outcomes were conversion with other techniques, duration of stay in hospital, number of procedures used per patient, and operating time. Data were pooled by meta-analysis.

RESULTS

Fourteen studies with 1600 participants were identified. Each arm contains 800 participants. There is no significant difference between the two arms regarding successful CBD stone clearance (RR = 0.96, P = 0.15), mortality (RR = 1.74, P = 0.33), morbidity (RR = 0.89, P = 0.32), conversion to additional procedure (RR = 1.44, P = 0.09), operating time (MD = -1.43 min, P = 0.95), hospital stay (MD = 1.31 days, P = 0.17), and retained stone rate (RR = 1.73, P = 0.38).

CONCLUSIONS

One- and two-stage management had similar efficacy and safety in terms of CBD stone clearance rate, mortality, morbidity, operating time, hospital stay, and retained stone rate. One-stage management may reduce additional procedure.

Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma

Introduction

Periampullary diverticula (PD) is caused by extraluminal pouching of duodenal mucosa. Using a very common endoscopic procedure to diagnose or treat gastrointestinal disorders, we encountered duodenal diverticulum.

Materials and methods

This is a retrospective, single-center study. Three thousand and sixteen patients on whom endoscopic retrograde cholangiopancreatography (ERCP) was performed at Ankara University Medical School, Department of Gastroenterology, from June 2009 to June 2014 were included to the study.

Results

Hundred and thirty patients (males 65, females 65) among the 3,016 had PD. Two hundred and sixty patients without diverticulum were randomly chosen from the 3,016 patients, as a control group [121 (47%) females, 139 (53%) males]. There was no statistical difference between the two groups. The mean age of the patients with PD was 69.9 years, while the mean age was 62.3 years for patients without PD (p < 0.001). Incidence for PD was 4.6%. The papilla of Vater was located in the inter-diverticular area (Type 1) in 9 patients (8.3%), at the edge of the diverticulum (Type 2) in 31 patients (28.4%), and at a distance of 2 to 3 cm from the papilla (Type 3) in 69 patients (63.3%).

Discussion

Although numerically more common bile duct stones occurred in patients with PD compared to those without PD, there was no statistical difference between the two groups. The rate of pancreato-biliary carcinomas was higher in patients without diverticulum. Cannulation was successful in both groups at the rate of 97.6 and 92% respectively, but cannulation failed more often in patients without PD. Duodenal perforation occurred in one patient with PD. Bleeding after sphincterotomy occurred in two patients without PD.

How to cite this article

Örmeci N, Deda X, Kalkan Ç, Tüzün AE, Karakaya F, Dökmeci A, Bahar DK, Özkan H, İdilman R, Çınar K. Impact of Periampullary Diverticula on Bile Duct Stones and Ampullary Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(1):31-34.

Comparison of endoscopic papillary balloon dilatation and endoscopic sphincterotomy for bile duct stones

Endoscopic treatment for bile duct stones is low-invasive and currently considered as the first choice of the treatment. For the treatment of bile duct stones, papillary treatment is necessary, and the treatments used at the time are broadly classified into two types; endoscopic papillary balloon dilatation where bile duct closing part is dilated with a balloon and endoscopic sphincterotomy (EST) where bile duct closing part is incised. Both procedures have advantages and disadvantages. Golden standard is EST, however, there are patients with difficulty for EST, thus we must select the procedure based on understanding of the characteristics of the procedure, and patient backgrounds.

Treatment of complicated biliary stones by percutaneous nephroscopy

AIM: To assess the clinical efficacy of percutaneous nephroscopy in the treatment of complicated biliary stones.

METHODS: Clinical data for 73 patients with complicated biliary stones treated by percutaneous nephroscopy at Yichun People's

Hospital between January 2013 and March 2015 were retrospectively analyzed. All cases were diagnosed by B ultrasound, CT or MRI before operation, and patients with abnormal coagulation function, high blood pressure or severe organ dysfunction were excluded. Patients were followed by outpatient examination, telephone interview, short message or instant messenger (WeChat) till August 2015.

RESULTS: The 73 cases of bile duct stones were treated by percutaneous nephroscopy combined with pneumatic lithotripsy. The success rate of lithotripsy was 100%. Among all patients, 48 (65.8%) had successful lithotripsy in the first session, 22 (30.1%) in the second or third session, and 3 (4.1%) in the third or fourth session. A female patient with intrahepatic diffuse stones achieved successful lithotripsy in the fourth session. Of 73 patients, 7 underwent left hepatic lobe resection and 2 underwent biliary enteric anastomosis. Three patients with postoperative indwelling T tube developed postoperative bleeding at the fistula site, and there were also two cases of postoperative abdominal distension and vomiting. No other serious complications occurred. The patients were followed for 3 to 12 mo, and the average follow-up duration was 10 mo. The recurrence rate of intrahepatic bile duct stones was 3/73.

CONCLUSION: Treatment of complicated bile duct calculi by percutaneous nephroscopy has advantages of high efficiency, short operation time, short hospitalization time and less hospitalization expenses and it is a safe, economical and efficient operation.

Endoscopic management of radio-opaque bile duct stones

BACKGROUND

Majority of the bile duct stones (BDS) are radiolucent (RL) and are amenable to conventional endoscopic extraction techniques. There is no publication that specifically discusses the optimal management of radio-opaque (RO) BDS and makes a distinction from the strategy followed for RL BDS.

METHODS

Data of patients with BDS managed endoscopically from January 2009 till June 2015 were retrospectively reviewed. Diagnosis of RO stone was established during initial fluoroscopy, just prior to obtaining a cholangiogram. Endoscopic retrograde cholangiopancreatography (ERCP) was done using therapeutic duodenoscope. Stone extraction was attempted initially using conventional techniques. Balloon sphincteroplasty or mechanical lithotripsy (ML) or both were done if conventional techniques failed. Cholangioscopy-guided intracorporeal holmium laser lithotripsy (LL) was done when all the above techniques failed.

RESULTS

Fifteen patients were found to have RO stones in the bile duct during the study period. ERCP was successful in all patients. Discrepancy of the stone size in relation to the lower CBD diameter was seen in eight patients (53.34 %). Stone extraction with conventional techniques was successful in 2/15 patients (13 %). Successful controlled radial expansion (CRE) balloon sphincteroplasty/ML was possible in 5/15 patients (33 %). Cholangioscopy guided LL was done in eight patients (53.34 %) with successful pulverization of RO BDS (100 %).

CONCLUSIONS

RO bile duct stones provide unique challenges for endoscopic management with success of conventional techniques in only about half of them (46 %). RO stones detected on fluoroscopy are extremely hard and difficult to crush with lithotripsy basket probably due to high calcium content. Cholangioscopy guided LL provides an excellent alternative management strategy.

Basket-in-catheter access for transcystic laparoscopic bile duct exploration: technique and results

BACKGROUND

When common bile duct (CBD) stones are detected during laparoscopic cholecystectomy, the insertion of baskets via the cystic duct (CD) can be difficult and may occasionally cause complications. We introduced a new technique 'basket in catheter' (BIC) for transcystic CBD exploration.

METHODS

Although cannulating the CD using a cholangiography catheter is successful in most cases, it may occasionally be difficult. Cystic duct anatomy may prevent the usually stiffer sharper tip of the basket, from entering the CBD, resulting in failure, perforation or a false passage. In the majority of our cases, the cholangiography catheter (CC) is not withdrawn from the duct should the intraoperative cholangiography show CBD stones. The tip of a basket is inserted into the CC and advanced to a predetermined distance, allowing the tip of the basket to exit the end of the CC into the CBD. The basket is then opened, advanced to feel the lower end and manipulated to trap the stone. The common hepatic duct is compressed gently to prevent stones from slipping upwards. The catheter and basket are pulled back together to extract the stone.

RESULTS

We have used this technique in 274 cases since 2010. The rate of transcystic versus choledochotomy stone extraction has increased, saving unnecessary choledochotomies. The percentage of transcystic exploration increased from 55 % for the period 2005-2009 to 70 % for the period 2010-2014. There were no conversions to open surgery and no retained stones. The morbidity rate was 4.0 % with no mortality.

CONCLUSIONS

We demonstrate a technique to facilitate the insertion of extraction baskets into the common bile duct using the cholangiography catheter as a guide. The 'basket-in-catheter' (BIC) technique for transcystic CBD exploration is easier and safer than inserting the basket alone.

Current status of peroral cholangioscopy in biliary tract diseases

Peroral cholangioscopy (POC) is an important tool for the management of a selected group of biliary diseases. Because of its direct visualization, POC allows targeted diagnostic and therapeutic procedures. POC can be performed using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope or via the insertion of a small-diameter endoscope directly into the bile duct. POC was first described in the 1970s, but the use of earlier generation devices was substantially limited by the cumbersome equipment setup and high repair costs. For nearly ten years, several technical improvements, including the single-operator system, high-quality images, the development of dedicated accessories and the increased size of the working channel, have led to increased diagnostic accuracy, thus assisting in the differentiation of benign and malignant intraductal lesions, targeting biopsies and the precise delineation of intraductal tumor spread before surgery. Furthermore, lithotripsy of difficult bile duct stones, ablative therapies for biliary malignancies and direct biliary drainage can be performed under POC control. Recent developments of new types of conventional POCs allow feasible, safe and effective procedures at reasonable costs. In the current review, we provide an updated overview of POC, focusing our attention on the main current clinical applications and on areas for future research.

Technical outcomes and complications of pediatric ERCP

BACKGROUND

Previous reports have suggested that endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients is safe, but because the total number of cases reported in the literature remains small, questions remain regarding safety and outcomes of this procedure in children.

METHODS

Pediatric patients who underwent ERCP were identified from diagnostic to billing codes. Medical records were examined for age, gender, diagnosis codes, indication, type of sedation, findings, interventions, and complications. Descriptive statistics were prepared for data including frequencies, percentages for categorical variables, and means and standard deviations for quantitative variables. Extensions of logistic regression were used to examine the relationship between demographic and clinical characteristics and post-ERCP pancreatitis.

RESULTS

Four hundred and twenty-five ERCPs were performed on 276 pediatric patients. Patient's age ranged from 72 days to 18 years, and there was equal gender distribution. Targeted duct cannulation was achieved in over 95% of cases, and therapeutic interventions were common (81.3%). The most common indications were biliary obstruction (43.3%) and chronic pancreatitis (26.8%). The most common complication was post-ERCP pancreatitis which occurred in 26 cases (7.7%), and the majority was mild by consensus definition. Procedural characteristics significantly associated with post-ERCP pancreatitis included: pancreatogram, pancreatic sphincterotomy, pancreatic duct stenting, and pancreatic duct stricture dilation. Immediate post-sphincterotomy bleeding occurred twice (1.1%), and both cases were successfully treated during the procedure. There was one instance of a possible delayed sphincterotomy bleed. No mortality was observed.

CONCLUSIONS

This retrospective review is one of the larger ERCP series reported in the pediatric population and adds to the growing body of literature supporting that ERCP can be safely applied in younger patients by skilled endoscopists. The complication rate found in this series closely parallels that observed in adults. Prospective studies of pediatric ERCP are still required to more definitively define the safe and appropriate use of this procedure in children.

Analyzing risk factors for early postoperative bile leakage based on Clavien classification in bile duct stones

OBJECTIVES

To identify the risk factors of bile leakage, with different severity, based on Clavien-Dindo complication classification system.

MATERIALS AND METHODS

A retrospective analysis of 943 eligible patients was performed. Sixty-eight patients, with bile leakage, were divided into 2 groups: mild bile leakage (grades I, II, n = 41) and severe bile leakage (grades III, IV, V, n = 27). Twenty-five potential factors were analyzed, by multivariate regression analyses, to identify independent risk factors of bile leakage.

RESULTS

The independent risk factors of bile leakage, for the entire cohort, included attacks of acute cholangitis within 1 month, associated biliary-enteric anastomosis (BEA), associated hepatectomy and previous biliary surgery. The independent risk factors for patients with mild bile leakage were attacks of acute cholangitis within 1 month, associated hepatectomy, and a history of previous biliary surgery. Similarly, the independent risk factors for patients with severe bile leakage were attacks of acute cholangitis within 1 month, associated hepatectomy, and associated BEA.

CONCLUSIONS

Risk factors for mild and severe postoperative bile leakage, in bile duct stones, were different.

Modern approach to cholecysto-choledocholithiasis

Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold standard of care for gallbladder calculi and isolated common bile duct stones is represented by laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, respectively, while a debate still exists regarding how to treat the two diseases at the same time. Many therapeutic options are also available when the two conditions are associated, including many different types of treatment, which local professionals often administer. The need to limit maximum discomfort and risks for the patients, combined with the economic pressure of reducing costs and utilizing resources, favors single-step procedures. However, a multitude of data fail to strongly demonstrate the superiority of any technique (including a two or multi-step approach), while rigorous clinical trials that include so many different types of treatment are still lacking, and it is most likely unrealistic to conduct them in the future. Therefore, the choice of the best management is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another.

Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg. 2013;206:457-463. [PMID: 23871320 DOI: 10.1016/j.amjsurg.2013.02.004]

BACKGROUND

Endoscopic retrograde cholangiopancreatography and laparoscopic common bile duct exploration are safe and efficient methods that have recently been used for the treatment of bile duct stones. The aim of this study was to compare the efficacy, safety, and surgical outcomes of the laparoscopic common bile duct exploration plus laparoscopic cholecystectomy (LCBDE+LC) and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy (ERCP+LC).

METHODS

One hundred twenty patients were prospectively randomized into 2 groups: LCBDE with LC in a single intervention and LC after ERCP.

RESULTS

The success rate of the LCBDE+LC group (96.5%) was found to be higher than for the ERCP+LC group (94.4%). Complication rates of the LCBDE+LC and ERCP+LC group were 7% and 11.1%, respectively. Complications requiring ERCP in the postoperative period after LCBDE+LC have been noted in 3.5% of cases.

CONCLUSIONS

Laparoscopic CBD exploration provides an alternative therapeutic approach that has less morbidity, is cost-effective, and allows earlier recovery with a reduced period of short-term disability.

Endoscopic papillary balloon dilation after sphincterotomy for difficult choledocholithiasis: A case-controlled study

AIM: To evaluate the efficacy and safety of endoscopic sphincterotomy (EST) + endoscopic papillary large balloon dilation (EPLBD) vs isolated EST.

METHODS: We conducted a retrospective single center study over two years, from February 2010 to January 2012. Patients with large (≥ 10 mm), single or multiple bile duct stones (BDS), submitted to endoscopic retrograde cholangio-pancreatography (ERCP) were included. Patients in Group A underwent papillary large balloon dilation after limited sphincterotomy (EST+EPLBD), using a through-the-scope balloon catheter gradually inflated to 12-18 mm according to the size of the largest stone and the maximal diameter of the distal bile duct on the cholangiogram. Patients in Group B (control group) underwent isolated sphincterotomy. Stones were removed using a retrieval balloon catheter and/or a dormia basket. When necessary, mechanical lithotripsy was performed. Complete clearance of the bile duct was documented with a balloon catheter cholangiogram at the end of the procedure. In case of residual lithiasis, a double pigtail plastic stent was placed and a second ERCP was planned within 4-6 wk. Some patients were sent for extracorporeal lithotripsy prior to subsequent ERCP. Outcomes of EST+EPLBD (Group A) vs isolated EST (Group B) were compared regarding efficacy (complete stone clearance, number of therapeutic sessions, mechanical and/or extracorporeal lithotripsy, biliary stent placement) and safety (frequency, type and grade of complications). Statistical analysis was performed using χ² or Fisher’s exact tests for the analysis of categorical parameters and Student’s t test for continuous variables. A P-value of less than 0.05 was considered statistically significant.

RESULTS: One hundred and eleven patients were included, 68 (61.3%) in Group A and 43 (38.7%) in Group B. The mean diameter of the stones was similar in the two groups (16.8 ± 4.4 and 16.0 ± 6.7 in Groups A and B, respectively). Forty-eight (70.6%) patients in Group A and 21 (48.8%) in Group B had multiple BDS (P = 0.005). Overall, balloon dilation was performed up to 12 mm in 10 (14.7%) patients, 13.5 mm in 17 (25.0%), 15 mm in 33 (48.6%), 16.5 mm in 2 (2.9%) and 18 mm in 6 (8.8%) patients, taking into account the diameter of the largest stone and that of the bile duct. Complete stone clearance was achieved in sixty-five (95.6%) patients in Group A vs 30 (69.8%) patients in Group B, and was attained within the first therapeutic session in 82.4% of patients in Group A vs 44.2% in Group B (P < 0.001). Patients submitted to EST+EPLBD underwent fewer therapeutic sessions (1.1 ± 0.3 vs 1.8 ± 1.1, P < 0.001), and fewer required mechanical (14.7% vs 37.2%, P = 0.007) or extracorporeal (0 vs 18.6%, P < 0.001) lithotripsy, as well as biliary stenting (17.6% vs 60.5%, P < 0.001). The rate of complications was not significantly different between the two groups.

CONCLUSION: EST+EPLBD is a safe and effective technique for treatment of difficult BDS, leading to high rates of complete stone clearance and reducing the need for lithotripsy and biliary stenting.

Pancreatico-biliary endoscopic ultrasound: A systematic review of the levels of evidence, performance and outcomes

Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, IIb, IIa, Ib and Ia, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.

Endoscopic sphincterotomy plus balloon dilation for large bile duct stones: An analysis of 80 cases

AIM: To evaluate the therapeutic efficacy and safety of endoscopic sphincterotomy (EST) plus balloon dilation for large bile duct stones.

METHODS: Eighty patients with bile duct stones larger than 1.2 cm, who received endoscopic retrograde eholangiopancreatography (ERCP) from January 2010 to October 2011 at our hospital, were randomly and equally divided into two groups to receive EST and EST plus balloon dilation (ESBD), respectively. Balloon dilation was conducted after small EST in the ESBD group, while conventional EST was used in the EST group.

RESULTS: All stones were removed successfully from 36 patients (90%) of the EST group and 38 (95%) patients of the ESBD group. Mechanical lithotripsy was used to fragment stones in 15 (37.5%) EST procedures and 4 (10%) ESBD procedures. The operation time was longer in the EST group than in the ESBD group (41.78 ± 10.41 vs 36.28 ± 8.64, P < 0.05). Bleeding occurred in two patients of the EST group but not in patients of the ESBD group. Fever, abdominal pain, and acute pancreatitis developed in 1, 1 and 2 patients in the EST group, while abdominal pain and acute pancreatitis in 2 and 1 patients in the ESBD group, respectively. There is no significant difference in the incidence of early complications between the two groups (10% vs 7.5%, P > 0.05). No patient died.

CONCLUSION: ESBD is superior to EST in terms of operating time and the use of mechanical lithotripsy in managing large bile duct stones.

Is ERCP really necessary in case of suspected spontaneous passage of bile duct stones?

AIM: To investigate the usefulness of magnetic resonance cholangiopancreatography (MRCP) and the need for endoscopic retrograde cholangiopancreatography (ERCP) in cases of suspected spontaneous passage of stones into the common bile duct.

METHODS: Thirty-six patients with gallbladder stones were clinically suspected of spontaneous passage of stones into the common bile duct because they presented with clinical symptoms such as abdominal pain and fever, and showed signs of inflammatory reaction and marked rise of hepatobiliary enzymes. These symptoms resolved and they showed normalized values of blood biochemical parameters after conservative treatment without evidence of stones in the common bile duct on MRCP. All these patients were subjected to ERCP within 3 d of MRCP to check for the presence of stones.

RESULTS: No stones were detected by ERCP in any patient, confirming the results of MRCP.

CONCLUSION: When clinical symptoms improve, blood biochemical parameters have normalized, and MRCP shows there are no stones in the common bile duct, it can be considered the stone has spontaneously passed and thus ERCP is not necessary.

An analysis and re-evaluation of biliary drainage procedures for patients with primary bile duct stones

AIM: To retrospectively evaluate the changes in biliary drainage procedures for patients with bile duct stones.

METHODS: The clinical records of 3691 patients with bile duct stones treated at our hospital from 1986 to 2007 were collected, while the clinical data of patients with bile duct stones reported in the literature between 1960 and 1980 were obtained by searching the Chinese Biomedical Literature Database (CBMDisc). The changes in biliary drainage procedures (e.g., T-Tube drainage and biliary-intestinal anastomosis) were analyzed. Moreover, the possible reasons behind such changes were explored.

RESULTS: During the periods from 1960 to1980, 1986 to 1996 and 1997 to 2007, T-Tube drainage and biliary-intestinal anastomosis were used in 74.70% and 16.90%, 35.20% and 38.42%, 70.30% and 10.16% of patients undergoing surgical therapy, respectively.

CONCLUSION: Over the past 50 years, the changes in biliary drainage procedures for patients with bile duct stones in China can be divided into three different stages, namely, biliary tract exploration plus T-Tube drainage, biliary-intestinal anastomosis, and radical treatment of focal infection plus T-Tube drainage.

Clinical usefulness of transpapillary removal of common bile duct stones by frequency doubled double pulse Nd:YAG laser

AIM: To study the efficacy and the safety of laser lithotripsy without direct visual control by using a balloon catheter in patients with bile duct stones that could not be extracted by standard technique.

METHODS: The seventeen patients (7 male and 10 female; mean age 67.8 years) with difficult common bile duct (CBD) stones were not amenable for conventional endoscopic maneuvers such as sphincterotomy and mechanical lithotripsy were included in this study. Laser wavelengths of 532 nm and 1064 nm as a double pulse were applied with pulse energy of 120 mJ. The laser fiber was advanced under fluoroscopic control through the ERCP balloon catheter. Laser lithotripsy was continued until the fragment size seemed to be less than 10 mm. Endoscopic extraction of the stones and fragments was performed with the use of the Dormia basket and balloon catheter.

RESULTS: Bile duct clearance was achieved in 15 of 17 patients (88%). The mean number of treatment sessions was 1.7 ± 0.6. Endoscopic stone removal could not be achieved in 2 patients (7%). Adverse effects were noted in three patients (hemobilia, pancreatitis, and cholangitis).

CONCLUSION: The Frequency Doubled Double Pulse Nd:YAG (FREDDY) laser may be an effective and safe technique in treatment of difficult bile duct stones.

ERCP in total situs viscerum inversus

A 69-year-old cholecystectomized female with known total situs viscerum inversus presented recurrent colicky pain in the left upper abdominal quadrant and jaundice. Laboratory parameters showed increased neutrophils and coniugated bilirubin of 5.53 mg/dl. US and MRCP confirmed total situs viscerum inversus and a dilatation of the intra- and extrahepatic ducts with a peripapillary 13 mm stone. ERCP, sphincterotomy and successful common bile duct stone extraction were performed in the conventional way. ERCP was carried out successfully despite situs inversus maintaining the patient in the prone position with the endoscopist on the right side of the table. Some authors have reported similar cases in whom ERCP was performed in other positions, while this report shows that an experienced endoscopist can achieve the same results in the conventional way as it is possible when anatomical changes, Billroth II or Roux-en-Y, or different positions of the patient, supine or on the left side, are present.