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Digital cholangioscopy-assisted, direct visualization-guided, radiation-free, endoscopic retrograde intervention for cholelithiasis: technical feasibility, efficacy, and safety

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Yadong Feng
Yadong Feng
Yan Liang
Yan Liang
Yan Liang
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Yang Liu
Yang Liu
Yang Liu
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Yinqiu Zhang
Yinqiu Zhang
Yinqiu Zhang
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Background Nonradiation, digital cholangioscope (DCS)-assisted endoscopic intervention for cholelithiasis has not been widely performed. For this study, we aimed to report the feasibility, efficacy, and safety of an established DCS-guided lithotomy procedure. Methods Data relating to biliary exploration, stone clearance, adverse events, and follow-up were obtained from 289 patients. The choledocholithiasis-related outcomes via the DCS-guided procedure were subsequently compared to those via conventional endoscopic retrograde cholangiopancreatography (ERCP). Results Biliary access was achieved in 285 patients. The technical success rate for the exploration of the common bile duct, the cystic stump, the hilar ducts, and secondary radicals was 100%. Moreover, the success rates were 98.4%, 61.7%, and 20.7%, for the exploration of the cystic duct, complete cystic duct, and gallbladder, respectively. Suspicious or confirmed suppurative cholecystitis, cholesterol polyps, and hyperplastic polyps were detected in 42, 23, and 5 patients, respectively. Stone clearance was achieved in one session in 285 (100%), 11 (100%), 13 (100%), 7 (100%), 6 (100%), and 3 (14.3%) patients with choledocholithiasis and hepatolithiasis, cystic duct stump stones, nondiffuse located intrahepatic lithiasis, a single cystic duct stone, a single gallbladder stone, and diffuse located intrahepatic lithiasis, respectively. Complete stone clearance for diffuse intrahepatic lithiasis was achieved in 19 (90.5%) patients, and fractioned re-lithotomy was performed in 16 (76.2%) patients. One patient developed mild acute cholangitis, and 12 developed mild pancreatitis. Stones recurred in one patient. Compared with conventional ERCP, DCS-guided lithotomy has the advantages of clearing difficult-to-treat choledocholithiasis and revealing concomitant biliary lesions, and this technique has fewer complications and a decreased risk of stone recurrence. Conclusions The technical profile, efficacy, and safety of nonradiation-guided and DCS-guided lithotomy are shown in this study. We provide a feasible modality for the endoscopic removal of cholelithiasis. Graphical abstract
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Vol.:(0123456789)
Surgical Endoscopy (2024) 38:1637–1646
https://doi.org/10.1007/s00464-024-10684-3
NEW TECHNOLOGY
Digital cholangioscopy‑assisted, direct visualization‑guided,
radiation‑free, endoscopic retrograde intervention forcholelithiasis:
technical feasibility, efficacy, andsafety
YadongFeng1,4 · YanLiang1· YangLiu1· YinqiuZhang2· ShuaijingHuang1· LihuaRen1· XiaojunMa3·
AijunZhou4· RuihuaShi1
Received: 5 September 2023 / Accepted: 2 January 2024 / Published online: 29 January 2024
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2024
Abstract
Background Nonradiation, digital cholangioscope (DCS)-assisted endoscopic intervention for cholelithiasis has not been
widely performed. For this study, we aimed to report the feasibility, efficacy, and safety of an established DCS-guided
lithotomy procedure.
Methods Data relating to biliary exploration, stone clearance, adverse events, and follow-up were obtained from 289 patients.
The choledocholithiasis-related outcomes via the DCS-guided procedure were subsequently compared to those via conven-
tional endoscopic retrograde cholangiopancreatography (ERCP).
Results Biliary access was achieved in 285 patients. The technical success rate for the exploration of the common bile duct,
the cystic stump, the hilar ducts, and secondary radicals was 100%. Moreover, the success rates were 98.4%, 61.7%, and
20.7%, for the exploration of the cystic duct, complete cystic duct, and gallbladder, respectively. Suspicious or confirmed
suppurative cholecystitis, cholesterol polyps, and hyperplastic polyps were detected in 42, 23, and 5 patients, respectively.
Stone clearance was achieved in one session in 285 (100%), 11 (100%), 13 (100%), 7 (100%), 6 (100%), and 3 (14.3%)
patients with choledocholithiasis and hepatolithiasis, cystic duct stump stones, nondiffuse located intrahepatic lithiasis, a
single cystic duct stone, a single gallbladder stone, and diffuse located intrahepatic lithiasis, respectively. Complete stone
clearance for diffuse intrahepatic lithiasis was achieved in 19 (90.5%) patients, and fractioned re-lithotomy was performed
in 16 (76.2%) patients. One patient developed mild acute cholangitis, and 12 developed mild pancreatitis. Stones recurred
in one patient. Compared with conventional ERCP, DCS-guided lithotomy has the advantages of clearing difficult-to-treat
choledocholithiasis and revealing concomitant biliary lesions, and this technique has fewer complications and a decreased
risk of stone recurrence.
and Other Interventional Te
chniques
* Yadong Feng
drfengyd@126.com
* Aijun Zhou
zaj970@sina.com
* Ruihua Shi
ruihuashi@126.com
1 Department ofGastroenterology, School ofMedicine,
Zhongda Hospital Southeast University, Southeast
University, 87 Dingjiaqiao Road, Nanjing210009, China
2 Department ofGastroenterology, Previously School
ofMedicine, Humanity Hospital, Southeast University, 3777
Yuexian Road, Xiamen361006, China
3 Department ofTranslational Research, Nanjing Microtech
Medical Technology Co. Ltd., 10 Gaoke 3rd Road,
Nanjing210018, China
4 Department ofGastroenterology, Lianshui People’s Hospital,
6 Hongri Road, Lianshui223400, China
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... More prospective studies with larger populations and longer follow-up periods are warranted to detect the long-term postoperative efficacy of this method. (2) Peroral cholangioscopy (POCS), which transforms an 'indirect' radiological visualization to a 'direct' endoscopic visualization of the biliary tree with the assistance of a digital cholangioscope, is increasingly applied in endoscopic lithotomy of difficult bile duct stones [79,80]; EPBD has a theoretical advantage in preserving SO function, especially when performed with a short dilation time and a small balloon size [45,81]; Combination of peroral cholangioscopy, appropriate EPBD and proper mechanical or laser lithotripsy may further help to expand the application of endoscopic lithotomy for the treatment of CBD stones, providing a better therapeutic effect by protecting SO with minimal stretch damage and avoiding scratching damage of stone fragments. (3) EPLBD is suitable for large or difficult CBD stones, but the structure and function of SO may be damaged to a greater extent, and post-damage repair can help to restore SO function after EST treatment [33,82]. ...
Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment
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A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.
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Digital cholangioscope assisted radiation-free bedside one-stage endoscopic lithotomy and biliary drainage for severe acute cholangitis caused by choledocholithiasis
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Endoscopic clearance of non‐complex biliary stones using fluoroscopy‐free direct solitary cholangioscopy: Initial multicenter experience
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The Usefulness of Peroral Cholangioscopy for Intrahepatic Stones
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Peroral cholangioscopy (POCS) is believed to be effective in treating intrahepatic stones; however, reports on its efficacy are few. We reviewed the results of intrahepatic stones treated with fluoroscopic guidance or POCS. This study included 26 patients who underwent endoscopic treatment for intrahepatic stones at our institution between January 2017 and December 2021. We retrospectively evaluated the procedure time and adverse events in the first session and the rate of complete stone removal. Complete stone removal was achieved in 92% (24/26); POCS was required in 16 of 26 (62%) procedures and the complete stone removal was achieved in 15 of 16 (94%) of these procedures. The POCS group had a significantly longer procedure time than the fluoroscopy group. Cholangitis incidence was high; however, no difference was noted between patients with and without POCS, and all cases were mild and treated conservatively. Endoscopic treatment for intrahepatic stones may lead to an increase in the incidence of cholangitis, requires specialized devices such as a cholangioscope, and should be performed in an established institution by experienced staff. POCS is useful for intrahepatic stones formed upstream of the stenosis and intrahepatic stones piled in the bile duct.
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Radiation-free digital cholangioscopy-guided laser lithotripsy for large common bile duct stones: feasibility and technical notes
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AimsAlthough endoscopic retrograde cholangiopancreatography (ERCP) for large common bile duct (CBD) stones is facilitated by digital cholangioscopy-guided lithotripsy, it is performed by fluoroscopy guidance. Here, we report our experience of non-radiation ERCP for large CBD stones using digital cholangioscopy-guided laser lithotripsy.Methods Sixteen patients with large CBD stones underwent non-radiation digital cholangioscopy-guided laser lithotripsy and lithotomy. Data relevant to procedure details, adverse events, and short-term follow-up were analyzed.ResultsBiliary access was achieved in all patients using standard guidewire-assisted cannulation, double-guidewire technique, and transpancreatic precut in twelve, two, and two patients, respectively. Balloons of 10 mm, 8 mm, and 6 mm in diameter were applied for EPBD in 8, 2, and 6 patients, respectively. Complete stone removal in one session was achieved in all patients. One round of laser lithotripsy was needed for stone ≤ 25 mm, and three-to-five rounds were needed for stones > 25 mm or multiple stones. One or two clips were used for endoscopic clipping. The time lengths of biliary access, digital cholangioscopy-assisted laser lithotripsy and stone extraction, and whole procedure were 3.5 ± 3.2 (0.5–12) minutes, 52.5 ± 30.6 (45–97) minutes, and 76 ± 23.3 (58–106) minutes, respectively. Asymptomatic hyperleukocytose, hyperamylasemia, and mild pancreatitis were present in 1, 2, and 1 patient(s), respectively. No other complications occurred. No cholangitis or recurrent CBD stones were observed.Conclusion Non-radiation digital cholangioscopy-guided laser lithotripsy is technically feasible and can be safely performed for endoscopic management of large CBD stones.
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Digital per-oral cholangioscopy to diagnose and manage biliary duct disorders: a single-center retrospective study
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Background and study aims Digital, per-oral cholangioscopy (POCS) allows diagnosis of biliary ducts disorders and treatment for complicated stones. We aimed to determine the diagnostic accuracy of digital POCS systems for stricture lesions and the factors precluding complete biliary stone clearance. Patients and methods We performed a retrospective analysis of a prospective database of 265 consecutive patients referred for POCS between December 2016 and July 2018. We first analyzed the diagnostic accuracy of digital POCS for malignant and benign stricture lesions in 147 patients. Then, we analyzed the factors associated with complete or partial biliary stone clearance achieved with electrohydraulic lithotripsy (EHL) delivered via POCS in 118 patients. Results In the diagnostic group, digital POCS achieved 91 % visual-impression sensitivity, 99 % specificity, 99 % positive and 91 % negative predictive values, and 63.64 positive and 0.09 negative likelihood ratios for malignancy diagnosis. In the therapeutic group, complete biliary stone clearance was achieved by EHL in 94.9 % patients; the mean stone size was 20 mm (10–40 mm). In multivariable analyses, a stone size > 20 mm (OR: 1.020, P < 0.001) and the number of stones ≥ 3 (OR: 1.276, P < 001) was associated with partial biliary stone clearance. Adverse events were reported in 3.3 % patients; no deaths were reported 30 days after the procedure. Conclusions Digital POCS has excellent diagnostic efficacy for biliary lesions. EHL via POCS is effective for complicated biliary stone clearance. Stone size (> 20 mm) and the number of stones (≥ 3) are associated with partial biliary stone clearance.
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Digital Cholangioscopy–assisted Nonradiation Endoscopic Retrograde Cholangiopancreatography for Retrieval of Common Bile Duct Stone
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Background: The use of nonradiation endoscopic retrograde cholangiopancreatography (NR-ERCP) for choledocholithiasis is still limited. Hereby, we introduced our experience of digital cholangioscopy (DCS)-assisted NR-ERCP for retrieval of common bile duct stones. Methods: Altogether, data of 132 patients who underwent DCS-assisted NR-ERCP for choledocholithiasis were collected. Procedure details, complications, and short-term follow-up were reviewed and analyzed and were compared with those of conventional endoscopic retrograde cholangiopancreatography (ERCP). Results: Routine stone extraction and laser lithotripsy were planned in 116 and 16 patients, respectively. Biliary access was successfully achieved by standard biliary cannulation and by advanced techniques in 99 and 33 patients, respectively. Complete stone removal was achieved in a single session in all patients. Routine stone extraction was performed in 117 patients, and laser lithotripsy was applied in 15 patients, among whom 14 patients with planned lithotripsy and 1 unexpected impacted stone found during the procedure. Unexpected right localized intrahepatic stones and purulent cholecystitis were found in 1 and 3 patients, respectively. Three mild and 1 moderate pancreatitis, 5 cases of hyperamylasemia, and 2 cases of leukocytosis occurred as complications. Short-term follow-up revealed no stone residual. Procedure details, technical success, and complications were not statistically different than conventional ERCP. Conclusions: DCS-assisted NR-ERCP is technically feasible, efficient, and safe for retrieval of common bile duct stones. This novel method is superior to conventional ERCP on detecting unexpected concomitant biliary diseases.
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Endoclip papillaplasty restores sphincter of Oddi function: Pilot study
Article
  • Dec 2020
Objectives Endoscopic sphincterotomy (EST) damaged the sphincter of Oddi (SO) function. This study aimed to explore the feasibility and efficacy of endoclip papillaplasty in restoring SO function. Methods This prospective pilot study included consecutive patients with choledocholithiasis (stone size ≥10 mm) who underwent large‐EST for stone removal, followed by endoclip papillaplasty, between May 2018 and March 2019. Results Thirty patients were enrolled in this trail. Overall, 80% of the patients had a SO basal pressure of >10 mmHg after endoclip papillaplasty. Manometric parameters, including SO basal pressure, phasic wave contraction amplitude, phasic waves per minute, recovered after endoclip papillaplasty (P > 0.05). There were no significant differences in the manometric parameters of SO between healing grades A and B. Six patients developed mild post‐endoscopic retrograde cholangiopancreatography pancreatitis, including three that had pancreatic stenting. Bile duct stone recurrence developed in 3.3% of the patients (1/30) during an 18‐month follow‐up. Conclusions Endoclip papillaplasty might restore SO function and possibly prevented biliary stone and cholangitis recurrence.
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