Specialized ultraslim upper endoscopes are being designed to facilitate access to the biliary tree for DPOC. Ultraslim upper endoscopes can be passed through the nasal cavity for performance of DPOC. Direct transnasal cholangioscopy has been reported for successful extraction of CBD stones.
Mechanical irritation of the stent on the stone is postulated to be one of the mechanisms.
Direct peroral cholangioscopy guided laser lithotripsy of a bile duct stone. The red laser light makes targeting of the stone easier).
Efforts are underway to develop the combined use of an intraductal anchoring balloon and an overtube especially designed for DPOC. Very recently, air embolism was reported following DPOC, resulting in a left sided hemiparesis. Endoscopists must be conscious of the fact that air embolism could remain asymptomatic, as in regional embolism (portal venous gas) or manifest as hypoxia, shock, cardiac arrest or cerebral ischemia as noted in this case.
In July 2011, we searched MEDLINE from 1982 to the present using the Medical Subject Headings terms common bile duct stone, endoscopic retrograde cholangiopancreatography, difficult stone, endoscopy, and the key word “common bile duct stone”. Full papers and abstracts in English language were considered. Important developments in research, reports from centers of excellence, and our own clinical experience in managing them, form the basis of this review article.
In a study involving 28 geriatric patients with CBD stones refractory to conventional endoscopic removal, endoscopic biliary stent placement combined with oral ursodeoxycholic acid and terpene therapy for a mean of six months led to significant reduction in the size of CBD stone. Subsequently, endoscopic stone removal was successfully performed in 26 of 28 patients with a mean of 1.7 ERCP procedures. This combination therapy may be of use for treatment of difficult to remove CBD stones in a subset of patients with significant co-morbidities and intolerance to prolonged endoscopic treatment modalities.
In most institutions that already have access to ESWL for treatment of renal calculi, no other purchases of equipment needs to be made. For ESWL direct contact with the calculi is not needed, and multiple stones can be managed simultaneously. ESWL can be of particular help in patients with abnormal anatomy such as those who have undergone Billroth-II or Roux-en-Y surgeries in whom endoscopic access to the major papilla is difficult.
Endoscopic papillary balloon dilatation
Common bile duct (CBD) stones are seen in approximately 7%-12% of patients who undergo cholecystectomy for symptomatic cholelithiasis and are a common indication for referral to a biliary endoscopist. They vary in size ranging from rather small (approximately 1-2 mm) to very large (> 3 cm). Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) and basket or balloon extraction are well established therapeutic procedures for the management of CBD stones. It is estimated that nearly 85%-95% of all CBD stones can be managed effectively by these conventional endoscopic methods[2,3]. Failure to clear the bile duct renders the patient vulnerable to biliary obstruction, cholangitis and pancreatitis, thereby increasing the morbidity[4,5]. The occurrence of acute cholangitis is associated with significant mortality, especially in the elderly, underscoring the need for early intervention to clear the bile duct of stones and to relieve the obstruction to achieve adequate biliary drainage. Extraction of CBD stones is one of the most commonly performed procedures by therapeutic endoscopists. With novel advances in extraction techniques and instruments emerging routinely, it is vital to keep abreast of the new developments in order to improve the outcome. This review focuses on the alternative endoscopic management options for the treatment of difficult to remove CBD stones.
To negate these limitations, the Spyglass Direct Visualization System (Boston Scientific Corp, Natick, Mass) was designed for single operator examination of the bile ducts, 4-way steering, and dedicated irrigation channels[48,49]. In a large international multicenter study conducted at 10 centers in the United States and 5 centers in Europe, ductal clearance was successfully achieved in 71% of the patients using the Spyglass cholangioscopy system. Despite its effectiveness, the spyglass system has been underutilized mainly due to its fiber optic image quality which is inferior to the video image quality offered by the new videocholangioscopes.
Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients.
In cases requiring LCBDE, LTSE should be the first choice, whereas LC may be restricted to large, multiple stones. LC with primary closure without external drainage of the CBDS is as effective and safe as the T-tube insertion approach.
Magnetic resonance cholangiopancreatography