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Direct Peroral Cholangioscopy in the Management of Difficult Biliary Stones: a New Tool to Confirm Common Bile Duct Clearance. Results of a Preliminary Study

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Andrea Anderloni1, Francesco Auriemma1, Alessandro Fugazza1, Edoardo Troncone2, Luis Maia3, Roberta Maselli1, Silvia Carrara1, Ferdinando D’Amico1, Paul J. Belletrutti4, Alessandro Repici4

1) Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
2) Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
3) Gastroenterology Department, Porto University Hospital Center, Porto, Portugal
4) Humanitas University, Rozzano, Milan, Italy

DOI: http://dx.doi.org/10.15403/jgld.2014.1121.281.bil

Background & Aims: Endoscopic sphincterotomy (ES) with stone extraction is the standard treatment for choledocholithiasis. After stone retrieval, balloon-occluded cholangiography is generally performed to confirm bile duct clearance but can miss residual stones particularly in patients with residual small-sized stones, a large bile duct or pneumobilia. In addition, difficult common bile duct (CBD) stones requiring advanced endoscopic techniques for retrieval are a potential risk factor for choledocholithiasis recurrence.
Methods: We performed a retrospective evaluation of a prospectively maintained procedures database. From July 2016 to December 2017, all patients with difficult CBD stones who underwent endoscopic retrograde cholangiopancreatography (ERCP) with papillary balloon dilation-assisted stone retrieval and subsequent direct per-oral cholangioscopy (DPOC) using standard gastroscopes to confirm CBD clearance were analyzed.
Results: Thirty-six patients who underwent ERCP and DPOC were included. Technical success, defined as deep intubation of CBD with hepatic hilum visualization, was achieved in 31 of 36 patients (86%). During DPOC, residual CBD stones were visualized and removed in 7 of 31 patients (22.5%). After a mean of 241 ± 56 days of follow-up post-DPOC, no serious adverse events were reported, and there was no evidence or
suspicion of recurrent choledocholithiasis.
Conclusions: Direct per-oral cholangioscopy immediately following difficult CBD stone removal was safe, feasible and accurate. In this setting, DPOC at the time of ERCP appears to be a very useful tool to achieve complete clearance of choledocholithiasis.
Key words: cholangioscopy – ERCP – difficult biliary stones – DPOC.
Abbreviations: CBD: common bile duct; DASE: dilation-assisted stone extraction; DPOC: direct per-oral cholangioscopy; EML: endoscopic mechanical lithotripsy; EPLBD: endoscopic papillary large-balloon dilation; ERCP: endoscopic retrograde cholangiopancreatography; ES: endoscopic sphincterotomy; IDUS: intraductal ultrasound.