Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones: laser lithotripsy using a disposable cholangioscope.
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SUBMITTER: Reddy DN
PROVIDER: S-EPMC8267960 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:INTRODUCTION: Laser lithotripsy of bile duct stones has become a widely accepted endoscopic treatment modality for giant, impacted, or very hard stones. The procedure is usually carried out under direct endoscopic control in view of the potential risk of bile duct injuries in "blind" laser application. AIMS: To investigate the use of a rhodamine 6G laser lithotriptor with an integrated optical stone tissue detection system (oSTDS). METHODS: From 1 September 1991 to 7 March 1997, 60 patients with giant or impacted common bile duct stones refractory to endoscopic papillotomy stone extraction, and mechanical lithotripsy were treated via the endoscopic retrograde route using a rhodamine 6G dye laser (595 nm, 2.5 micros, 80-150 mJ pp, Lithognost Telemit/Baasel Corp., Germany) with integrated oSTDS. In case of tissue contact oSTDS cuts off the laser pulse after 190 ns (transmission of 5-8% of the total pulse energy). 47 patients (78.3%) were subjected to x ray targeting (oSTDS) alone, five (8.3%) to choledochoscope targeting alone, and eight (13.3%) to both techniques. RESULTS: At the end of treatment 52 (87%) patients were completely stone-free. The only major complications included transient haemobilia, cholangitis, and pancreatitis in five patients. All five were successfully treated by conservative methods. CONCLUSIONS: Laser lithotripsy using the described rhodamine 6G dye laser with oSTDS seems to be safe and effective and allows "blind" fragmentation of difficult common bile duct stones under radiological control only.
| S-EPMC1727348 | biostudies-other
Project description:Background and study aimsBile stones represent a highly prevalent condition and abnormalities of the biliary tree predispose to stone recurrence due to development of biliary stasis. In our study, we assessed the importance of an altered bile duct course for stone formation.Patients and methods1,307 patients with choledocholithiasis in the absence of any associated hepatobiliary disease who underwent endoscopic retrograde cholangiopancreatography (ERCP) between 2002 and 2009 were analysed. The angle enclosed between the horizontal portion of the common bile duct (CBD) and the horizontal plane was measured (angle ?). Oblique common bile duct (OCBD) was defined as a CBD with angle ? < 45°.Results103 patients (7.9%) were found to harbour OCBD and these were compared to 104 randomly selected control subjects. Compared to controls, OCBD patients were (i) significantly older (72 ± 13 vs. 67 ± 13, p<0.00001); (ii) more frequently underwent a cholecystectomy (p = 0.02) and biliary surgery (p = 0.003) prior to the diagnosis and (iii) more often developed chronic pancreatitis (p = 0.04) as well as biliary fistulae (p = 0.03). Prior to and after ERCP, OCBD subjects displayed significantly elevated cholestatic parameters and angle ? negatively correlated with common bile duct diameter (r = -0.29, p = 0.003). OCBD subjects more often required multiple back-to-back ERCP sessions to remove bile stones (p = 0.005) as well as more ERCPs later on due to recurrent stone formation (p<0.05).ConclusionOCBD defines a novel variant of the biliary tree, which is associated with chronic cholestasis, hampers an efficient stone removal and predisposes to recurrence of bile duct stones.
| S-EPMC3554756 | biostudies-literature
Project description:BackgroundCommon bile duct (CBD) stones can be managed by either endoscopic retrograde cholangiopancreatography (ERCP) or laparoscopic common bile duct exploration (LCBDE). The aim of this survey was to document the management of CBD stones by European-African HPB Association (E-AHPBA) members.MethodsAll 331 members of the E-AHPBA were invited by personal email to participate to an online survey.ResultsNinety-three (28%) surgeons replied within 2 months. Responding surgeons were attending surgeons (84%), working as HPB surgeons (75%) in academic hospitals (73%). In patients with clinically suspected CBD stones, MRCP was the preferred diagnostic test for 61% of respondents. LCBDE was the preferred therapeutic strategy for 11 (12%) respondents only. Previous gastric surgery was an absolute contraindication to ERCP for 47% of respondents. Absence of CBD dilation was considered an absolute contraindication for LCBDE in 24% of respondents. Yearly caseload exceeded 10 patients for only 30% of 56 centers performing LCBDE. The transcystic approach was preferred by 39% of surgeons performing LCBDE. There was considerable variation amongst respondents with regard to type and duration of drainage, bile duct closure technique and follow-up after LCBDE.ConclusionIndications for single-stage LCBDE are not standardized and do not appear well established across E-AHPBA members.
| S-EPMC5144544 | biostudies-literature
Project description:BACKGROUND: It is controversial whether selective endoscopic sphincterotomy or routine laparoscopic bile duct exploration is the optimal treatment for choledocholithiasis. Magnetic resonance cholangio-pancreatography (MRCP) is a safe and accurate imaging modality; this study evaluated its use in a clinical algorithm for the management of suspected choledocholithiasis. PATIENTS AND METHODS: Consecutive patients presenting with suspected common bile duct (CBD) stones were managed according to an algorithm involving the selective use of MRCP to identify patients who required endoscopic sphincterotomy and bile duct clearance. Following radiological demonstration of a clear CBD, all patients were considered for cholecystectomy. RESULTS: From 157 consecutive patients, 68 proceeded straight to endoscopic sphincterotomy, which was therapeutic in 59. Of 89 who underwent MRCP, choledocholithiasis was demonstrated in 29; subsequent endoscopic sphincterotomy was therapeutic in 22. MRCP demonstrated a clear CBD in the remaining 60 patients. Seventy-four patients subsequently underwent cholecystectomy, with a conversion rate of 9% and a median postoperative stay of 1 day. There were no instances of post-sphincterotomy pancreatitis or haemorrhage requiring transfusion. CONCLUSION: An algorithm involving selective MRCP with endoscopic sphincterotomy is a safe, effective means of managing suspected choledocholithiasis, particularly where the expertise, equipment or theatre time for laparoscopic bile duct exploration is not routinely available.
| S-EPMC2020789 | biostudies-other
Project description:Background and aimsSingle-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis.MethodsA cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases.ResultsThe three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295.ConclusionsEarly utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.
| S-EPMC8600178 | biostudies-literature
Project description: Not available
| S-EPMC7332728 | biostudies-literature
Project description:BACKGROUND: Transduodenal sphincteroplasty (TDS) offers permanent prophylaxis against further stones in the common bile duct (CBD) by allowing continuous free efflux of bile from the papilla. PATIENTS AND RESULTS: In a personal series of 267 consecutive operations, four patients underwent further treatment for recurrent CBD stones during a median follow-up of 12 years. Three of them received Roux-en-Y biliary diversion and had no further symptoms; the fourth patient remains well four years after endoscopic extraction of stones. DISCUSSION: Recurrent stone formation is rare after an adequate TDS and probably reflects retained food debris within the CBD. Initial treatment may be endoscopic, but biliary diversion is needed for those with recurrent symptoms.
| S-EPMC2020535 | biostudies-other
Project description:Background and aimsEndoscopic retrograde cholangiopancreatography is the preferred strategy for the management of biliary and pancreatic duct stones. However, difficult stones occur, and electrohydraulic (EHL) and laser lithotripsy (LL) have emerged as treatment modalities for ductal clearance. Recently, single-operator cholangioscopy was introduced, permitting the routine use of these techniques. We aimed to evaluate the clinical effectiveness of cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones.MethodsThis is a prospective clinical study - conducted at two affiliated university hospitals - of 17 consecutive patients with difficult biliary and pancreatic stones who underwent single-operator cholangioscopy-guided lithotripsy using two techniques: holmium laser lithotripsy (HL) or bipolar EHL. We analyzed complete ductal clearance as well as the impact of the location and number of stones on clinical success and evaluated the efficacy of the two techniques used for cholangioscopy-guided lithotripsy and procedural complications.ResultsTwelve patients (70.6%) had stones in the common bile duct/common hepatic duct, 2 patients (17.6%) had a stone in the cystic stump, and 3 patients (17.6%) had stones in the pancreas. Sixteen patients (94.1%) were successfully managed in 1 session, and 1 patient (5.9%) achieved ductal clearance after 3 sessions including EHL, LL, and mechanical lithotripsy. Eleven patients were successfully submitted to HL in 1 session using a single laser fiber. Six patients were treated with EHL: 4 patients achieved ductal clearance in 1 session with a single fiber, 1 patient obtained successful fragmentation in 1 session using two fibers, and 1 patient did not achieve ductal clearance after using two fibers and was successfully treated with a single laser fiber in a subsequent session. Complications were mild and were encountered in 6/17 patients (35.2%), including fever (n = 3), pain (n = 1), and mild pancreatitis (n = 1). Conclusions: Cholangioscopy-guided lithotripsy using LL or EHL in patients with difficult biliary or pancreatic stones is highly effective with transient and minimal complications. There is a clear need to further compare EHL and HL in order to assess their role in the success of cholangioscopy-guided lithotripsy.
| S-EPMC6454387 | biostudies-literature
Project description:Current evidence supporting the efficacy of peroral cholangioscopy (POC) in the evaluation and management of difficult bile duct stones and indeterminate strictures is limited. The aims of this systematic review and meta-analysis were to assess the following: the efficacy of POC for the therapy of difficult bile duct stones, the diagnostic accuracy of POC for the evaluation of indeterminate biliary strictures, and the overall adverse event rates for POC.Patients referred for the removal of difficult bile duct stones or the evaluation of indeterminate strictures via POC were included. Search terms pertaining to cholangioscopy were used, and articles were selected based on preset inclusion and exclusion criteria. Quality assessment of the studies was completed with a modified Newcastle-Ottawa Scale. After critical literature review, relevant outcomes of interest were analyzed. Meta-regression was performed to examine potential sources of between-study variation. Publication bias was assessed via funnel plots and Egger's test.A total of 49 studies were included. The overall estimated stone clearance rate was 88 % (95 % confidence interval [95 %CI] 85 % - 91 %). The accuracy of POC was 89 % (95 %CI 84 % - 93 %) for making a visual diagnosis and and 79 % (95 %CI 74 % - 84 %) for making a histological diagnosis. The estimated overall adverse event rate was 7 % (95 %CI 6 % - 9 %).POC is a safe and effective adjunctive tool with endoscopic retrograde cholangiopancreatography (ERCP) for the evaluation of bile duct strictures and the treatment of bile duct stones when conventional methods have failed. Prospective, controlled clinical trials are needed to further elucidate the precise role of POC during ERCP.
| S-EPMC4798839 | biostudies-other
Project description:To compare the efficacy of a session of extracorporeal shock wave lithotripsy (ESWL) before endoscopic retrograde cholangiopancreatography (ERCP) vs ERCP only for problematic and large common bile duct (CBD) stones.Adult patients with CBD stones for whom initial ERCP was unsuccessful because of the large size of CBD stones were identified. The patients were randomized into two groups, an "ESWL + ERCP group" and an "ERCP-only" group. For ESWL + ERCP cases, ESWL was performed prior to ERCP. Clearance of the CBD, complications related to the ESWL/ERCP procedure, frequency of mechanical lithotripsy use and duration of the ERCP procedure were evaluated in both groups.There was no significant difference in baseline characteristics between the two groups. A session of ESWL before ERCP compared with ERCP only resulted in similar outcomes in terms of successful stone removal within the first treatment session (74.2% vs 71.0%, P = 0.135), but a higher clearance rate within the second treatment session (84.4% vs 51.6%, P = 0.018) and total stone clearance (96.0% vs 86.0%, P = 0.029). Moreover, ESWL prior to ERCP not only reduced ERCP procedure time (43 ± 21 min vs 59 ± 28 min, P = 0.034) and the rate of mechanical lithotripsy use (20% vs 30%, P = 0.025), but also raised the clearance rate of extremely large stones (80.0% vs 40.0%, P = 0.016). Post-ERCP complications were similar for the two groups.Based on the higher rate of successful stone removal and minimal complications, ESWL prior to ERCP appears to be a safe and effective treatment for the endoscopic removal of problematic and large CBD stones.
| S-EPMC5526765 | biostudies-other