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.

Endoscopic Treatment of Upper Tract Urothelial Carcinoma: Challenging the Definition of the Maximal Lesion Size for Safe Ablation

Introduction: With advances in endoscopic treatment of upper tract urothelial carcinoma (UTUC) lesions, the recommended upper limit of lesion size amenable to laser ablation was set to 2 cm. However, this limit is based on expert opinion only, and debate still exists regarding this definition. Objective: To determine the maximal size of the tissue, for which total endoscopic ablation with laser energy is achievable, from a laser performance perspective. Materials and Methods: Simulating endoscopic surgery conditions, renal tissue blocks from pork kidneys in growing size from 1 cm3 to 3 cm3 were totally ablated with Ho:YAG laser (1 J, 10 Hz). The time to ablation was recorded for each tissue mass. Following the ablation, each sample was inspected microscopically by an expert pathologist to determine the extent to which the tissue was destroyed. Results: Time to ablation ranged from 16.4 min for a 1 cm3 mass, to 69.7 min for a 3 cm3 mass. Histologic evaluation after laser ablation showed that ablation was achieved in all tissue masses, and no “unaffected” tissue was present, even for lesions with a size of 3 cm3. Conclusions: This study showed that laser ablation can be achieved for tumor lesions up to a size of 3 cm3. The results of this study can contribute to the debate regarding the limits of endoscopic management of UTUC lesions and strengthen the recommended upper limit of 2 cm3 for endoscopic treatment of tumor lesions.

Ogilvie’s syndrome—is there a cutoff diameter to proceed with upfront surgery?

Purpose Although Ogilvie’s syndrome was first described about 70 years ago, its etiology and pathogenesis are still not fully understood. But more importantly, it is also not clear when to approach which therapeutic strategy. Methods Patients who were diagnosed with Ogilvie’s syndrome at our institution in a 17-year time period (2002–2019) were included and retrospectively evaluated regarding different therapeutical strategies: conservative, endoscopic, or surgical. Results The study included 71 patients with 21 patients undergoing conservative therapy, 25 patients undergoing endoscopic therapy, and 25 patients undergoing surgery. However, 38% of patients (n = 8) who were primarily addressed for conservative management failed and had to undergo endoscopy or even surgery. Similarly, 8 patients (32%) with primarily endoscopic treatment had to proceed for surgery. In logistic regression analysis, only a colon diameter ≥ 11 cm (p = 0.01) could predict a lack of therapeutic success by endoscopic treatment. Ninety-day mortality and overall survival were comparable between the groups. Conclusion As conservative and endoscopic management fail in about one-third of patients, a cutoff diameter ≥ 11 cm may be an adequate parameter to evaluate surgical therapy.

Endoscopic management of non-ampullary duodenal adenomas

Duodenal polyps are found in 0.1 % to 0.8 % of all upper endoscopies. Duodenal adenomas account for 10 % to 20 % of these lesions. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis. Endoscopy is the cornerstone of management of duodenal adenomas, allowing for diagnosis and treatment, primarily by endoscopic mucosal resection. The endoscopic treatment of duodenal adenomas has a high morbidity, reaching 15 % in a prospective study, consisting of bleeding and perforations, and should therefore be performed in expert centers. The local recurrence rate ranges from 9 % to 37 %, and is maximal for piecemeal resections of lesions > 20 mm. Surgical resection of the duodenum is flawed with major morbidity and considered a rescue procedure in cases of endoscopic treatment failures or severe endoscopic complications such as duodenal perforations. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of non-ampullary duodenal adenomas.

Endoscopic management of cystic duct stones and Mirizzi’s syndrome: experience at an academic medical center

Background and study aims Cystic duct stones (CDS) are challenging to treat with conventional ERCP techniques due to the small diameter and tortuous nature of the cystic duct. There have been limited studies focused on endoscopic management of CDS. We present our experience managing CDS endoscopically and demonstrate that new advances in endoscopic technology have rendered CDS easier to manage. Patients and methods From 2013 to 2020, we prospectively maintained a database of patients undergoing endoscopic management of CDS. ERCP was performed in all patients, and if unsuccessful in removing stones, cholangioscopy with electrohydraulic lithotripsy (EHL) was utilized. All patients were followed in clinic for outcomes. Results Of 5,123 ERCPs performed at our institution during the study period, 21 patients were diagnosed with CDS. Six patients were successfully treated with conventional ERCP alone. Cholangioscopy with EHL was used in 15 patients undergoing 18 procedures to achieve stone clearance. CDS clearance was achieved in all patients. There was one adverse event (post-ERCP pancreatitis). Spyglass DS was associated with a significant decrease in average procedure time in comparison to first-generation SpyGlass (89.3 vs. 54.4 minutes, P = 0.004). Thirteen patients (87 %) were discharged from the hospital within 24 hours. The median follow-up duration was 23.2 months. Conclusions Endoscopy should be the preferred management strategy for CDS, especially in patients with prior cholecystectomy. Surgical outcomes have been associated with high patient morbidity and hospital length of stay. Our case series is the largest cohort of CDS patients successfully managed with cholangioscopy and EHL in the United States.