Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.

Post-ERCP Dormia basket impaction: a case report and literature review

The incidence of Common bile duct stones (CBD) in patients undergoing cholecystectomy is 10%. The present-day management of common bile duct stone may be pre-, intra-, or post-operative Endoscopic retrograde cholangio-pancreatography (ERCP) with stone extraction. The reported complications of ERCP and CBD stone extraction range from 5 to 10% cases, that might be life threatening. Herein, we reported a case of calculus obstructive jaundice and cholangitis. Unfortunately, trials for ERCP and stone retrieval was followed by impacted Dormia basket which was successfully managed by surgerys.

EUS and ERCP in the Same Session for Biliary Stones: From Risk Stratification to Treatment Strategy in Different Clinical Conditions

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction is the treatment of choice for choledocholithiasis, reaching a successful clearance of the common bile duct (CBD) in up to 90% of the cases. Endoscopic ultrasound (EUS) has the best diagnostic accuracy for CBD stones, its sensitivity and specificity range being 89–94% and 94–95%, respectively. Traditionally seen as two separate entities, the two worlds of EUS and ERCP have recently come together under the new discipline of bilio-pancreatic endoscopy. Nevertheless, the complexity of both EUS and ERCP led the European Society of Gastrointestinal Endoscopy to identify quality in endoscopy as a top priority in its recent EUS and ERCP curriculum recommendations. The clinical benefits of performing EUS and ERCP in the same session are several, such as benefiting from real-time information from EUS, having one single sedation for both the diagnosis and the treatment of biliary stones, reducing the risk of cholangitis/acute pancreatitis while waiting for ERCP after the EUS diagnosis, and ultimately shortening the hospital stay and costs while preserving patients’ outcomes. Potential candidates for the same session approach include patients at high risk for CBD stones, symptomatic individuals with status post-cholecystectomy, pregnant women, and those unfit for surgery. This narrative review discusses the main technical aspects and evidence from the literature about EUS and ERCP in the management of choledocholithiasis.

831 Bouveret’s Syndrome (A Gallstone Disease Causing Gastric Outlet Obstruction): A Case Series and Review of Literature

Bouveret’s syndrome refers to a gastric outlet obstruction due to the impaction of a large gallstone following retrograde migration via a bilio-duodenal fistula. Although no clear management guideline has been formulated, different treatment modalities have been described, including endoscopic stone removal using classical endoscopic devices, like snares and forceps; or fragmentation of stones with new devices, such as laser and extracorporeal shockwave lithotripsy (EWSL). We report a case series of Bouveret’s syndrome with interesting radiological and endoscopic findings which have been successfully managed either via endoscopic measures such as stone extraction and/or duodenal stenting, or surgical intervention. The report is followed by a literature review including diagnostic and management options of this rare condition. All our patients were elderly with multiple comorbidities. Two patients presented with upper gastro-intestinal bleeding, while the other two presented with abdominal pain and bilious vomiting. The diagnosis was confirmed by computerised tomography (CT) scan and upper gastro-intestinal endoscopy. Endoscopic stone removal was successful in one case. In one patient, stone was fragmented but could not be removed completely, so he was managed via duodenal stent insertion. The other two patients required surgical intervention. One case was complicated by gallstone ileus which required laparotomy and extraction of stones from two sites, while the other required subtotal cholecystectomy, stone extraction and repair of duodenal fistula. The patients recovered well. The diagnosis of Bouveret’s Syndrome is made after performing appropriate imaging studies. The first line management option is endoscopic treatment. If this fails, surgical intervention is recommended.

EUS-guided biliary interventions for benign diseases and unsuccessful ERCP – a prospective unicenter feasibility study on a large consecutive patient cohort

Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for the treatment of biliary obstruction of any etiology. However, cannulation failure of the common bile duct (CBD) by ERCP occurs in 5–10%. Alternatives after a failed ERCP are re-ERCP by an expert endoscopist, percutaneous transhepatic cholangio drainage (PTCD), (balloon) enteroscopy-assisted ERCP, or surgery. Endoscopic ultrasonography-guided drainage of the bile ducts (EUS-BD) is becoming the standard of care in tertiary referral centers for cases of failed ERCP in patients with malignant obstruction of the CBD. In expert hands, EUS-guided biliary drainage has excellent technical/clinical success rates and lower complication rates compared to PTCD. Despite the successful performance of EUS-BD in malignant cases, its use in benign cases is limited. The aim of this study (design, systematic prospective clinical observational study on quality assurance in daily clinical practice) was to evaluate the efficacy and safety of EUS-BD in benign indications. Patients and methods Patients with cholestasis and failed ERCP were recruited from a prospective EUS-BD registry (2004–2020). One hundred and three patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal = 474). Indications of EUS-BDs included surgically altered anatomy (n = 65), atypical bile duct percutaneous transhepatic cholangio orifice at the duodenal junction from the longitudinal to the horizontal segment (n = 1), papilla of Vater not reached due to the gastric outlet/duodenal stenoses (n = 6), papilla that cannot be catheterized (n = 24), and proximal bile duct stenosis (n = 7). The primary endpoint was technical and clinical success. Secondary endpoints were procedure-related complications during the hospital stay. Results 103 patients with EUS-BD and benign cholestasis were extracted from the registry (nTotal=474). Different transluminal access routes were used to reach the bile ducts: transgastric (n = 72/103); -duodenal (n = 16/103); -jejunal (n = 14/103); combined -duodenal and -gastric (n = 1/103). The technical success rate was 96 % (n = 99) for cholangiography. Drainage was not required in 2 patients; balloon dilatation including stone extraction was sufficient in 17 cases (16.5 %; no additional or prophylactic insertion of a drain). Transluminal drainage was achieved in n = 68/103 (66 %; even higher in patients with drain indication only) by placement of a plastic stent (n = 29), conventional biliary metal stents (n = 24), HotAXIOS stents (n = 5; Boston Scientific, Ratingen, Germany), Hanaro stents (n = 6; Olympus, Hamburg, Germany), HotAXIOS stents and plastic stents (n = 1), HotAXIOS stents and metal stents (n = 1) and metal stents and plastic stents (n = 2). Techniques for stone extraction alone (nSuccessful=17) or stent insertion (nTotal = 85; nSuccessful=85 – rate, 100 %) and final EUS-BD access pathway included: Rendezvous technique (n = 14/85; 16.5 %), antegrade internal drainage (n = 20/85; 23.5 %), choledochointestinostomy (n = 7/85; 8.2 %), antegrade internal and hepaticointestinostomy (n = 22/85; 25.9 %), hepaticointestinostomy (n = 21/85; 24.7 %), choledochointestinostomy and hepaticointestinostomy (n = 1/85; 1.2 %).The complication rate was 25 % (n = 26) – the spectrum comprised stent dislocation (n = 11), perforation (n = 1), pain (n = 2), hemorrhage (n = 6), biliary ascites/leakage (n = 3) and bilioma/liver abscess (n = 3; major complication rate, n = 12/68 – 17.6 %). Re-interventions were required in 19 patients (24 interventions in total). Discussion EUS-BD can be considered an elegant and safe alternative to PTCD or reoperation for failed ERCP to achieve the necessary drainage of the biliary system even in underlying benign diseases. An interventional EUS-based internal procedure can resolve cholestasis, avoid PTCD or reoperation, and thus improve quality of life. Due to the often complex (pathological and/or postoperative) anatomy, EUS-BD should only be performed in centers with interventional endoscopy/EUS experience including adequate abdominal surgery and interventional radiology expertise in the background. This enables adequately adapted therapeutic management in the event of challenging complications. It seems appropriate to conduct further studies with larger numbers of cases to systematize the approach and peri-interventional management and to successively develop specific equipment.

Gallstone ileus: the importance of individualized management

Gallstone ileus represents a complication of cholelithiasis, which in the literature has been reported as a rare cause of mechanical intestinal obstruction, however, the reported incidence is not so low, especially after 65 years of age. The formation of a bilioenteric fistula allows the passage of a large gallstone into the intestine, usually impacting the distal intestine. It is associated with a mortality that ranges between 12 and 27%. Treatment is surgical, although there is no consensus on which of the surgical techniques is the one of choice. We report the case of an 87-year-old male patient who was admitted to the emergency department with intestinal obstruction. He was diagnosed with gallstone ileus and was treated surgically with exploratory laparotomy, enterotomy with stone extraction, and primary closure. The evolution was favorable and without complications.