Original Article
Outcomes of Single-Operator Cholangioscopy-Guided Lithotripsy in Patients with Difficult Biliary and Pancreatic StonesCanena J.a,g,h · Lopes L.b,e,f · Fernandes J.b,c · Alexandrino G.a · Lourenço L.a · Libânio D.b,d · Horta D.a · Giestas S.b · Reis J.aaDepartment of Gastroenterology, Professor Doutor Fernando Fonseca Hospital, Amadora, Portugal
bDepartment of Gastroenterology, Santa Luzia Hospital – Unidade Local de Saúde Alto Minho, Viana do Castelo, Portugal cGastroenterology Department, Centro Hospitalar Cova da Beira, Covilhã, Portugal dDepartment of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal eLife and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal fICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal gCintesis – Center for Health Technology and Services Research, Porto, Portugal hDepartment of Gastroenterology, Nova Medical School-Faculty of Medical Sciences, Lisbon, Portugal Prof. Jorge Canena Department of Gastroenterology Professor Doutor Fernando Fonseca Hospital, IC 19 PT–2720-276 Amadora (Portugal) E-Mail jmtcanena@live.com.pt |
|
Do you have an account?
Abstract
Background and Aims: Endoscopic 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. Methods: This 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. Results: Twelve 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.
© 2018 Sociedade Portuguesa de Gastrenterologia Published by S. Karger AG, Basel
Resultados da Utilização da Colangioscopia de Operador Único na Litotrícia de Cálculos Difíceis Biliares e Pancreáticos
Palavras Chave
CPRE · Colangioscopia · Litotrícia por laser · Litotrícia eletrohidráulica ·
Resumo
Introdução: A CPRE é o exame preferencial para a remoção de cálculos biliares e pancreáticos. Em situações de cálculos difíceis foram propostas novas modalidades terapêuticas como a litotrícia electro-hidráulica (LEH) e a litotrícia por laser (LL). Recentemente a disponibilidade da colongioscopia de operador-único tornaram estas técnicas mais acessíveis e fáceis de realizar. Procuramos avaliar a eficácia clínica de litotrícia guiada por colangioscopia recorrendo à LEH ou à LL em doentes com cálculos biliares e pancreáticos difíceis. Métodos: Estudo prospetivo, conduzido em 2 Hospitais associados à Universidade e englobando 17 doentes consecutivos com cálculos difíceis biliares e pancreáticos, estes doentes foram tratados com litotrícia guiada por colangioscopia recorrendo a LEH ou LL. Analisamos a limpeza completa dos ductos, bem como o impato do número de pedras e localização no sucesso clínico, associada à avaliação das 2 técnicas de litotrícia e complicações desta abordagem terapêutica. Resultados: Doze doentes (70.6%) tinham cálculos no colédoco/hepático comum, 2 doentes (17.6%) tinham um cálculo único no coto do cístico e 3 doentes (17.6%) apresentavam cálculos pancreáticos. Dezasseis (94.1%) doentes foram tratados com sucesso numa única sessão e o restante (5.9%) doente necessitou de 3 sessões incluído LEH, LL e litotrícia mecânica para obter limpeza dos ductos. Onze doentes foram tratados com LL e obtiveram sucesso clínico numa única sessão com uma fibra única de laser. Seis doentes foram tratados com LEH: 4 doentes obtiveram sucesso clínico numa única sessão com 1 fibra; 1 doente necessitou de 2 fibras para obter limpeza ductal numa sessão única. O último doente falhou a limpeza dos ductos com duas fibras de LEH e necessitou de sessão adicional com Laser (uma fibra) para obter fragmentação adequada dos cálculos. As complicações foram ligeiras em 6/17 (35.2%) doentes e incluíram febre (n = 4), dor (n = 1) e pancreatite ligeira (n = 1). Conclusões: A litotrícia guiada por colangioscopia com recurso a LEH ou LL em doentes com cálculos difíceis biliares e pancreáticos é muito eficaz e está associada a complicações transitórias e ligeiras. Existe clara necessidade de realizar estudos comparativos entre LEH e LL.
Related Articles:
References
- Canena J: Once upon a time a guideline was used for the evaluation of suspected choledocholithiasis: a fairy tale or a nightmare? GE Port J Gastroenterol 2018; 25: 6–9.
- Maydeo A, Kwek BEA, Bhandari S, Bapat M, Dhir V: Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos). Gastrointest Endosc 2011; 74: 1308–1314.
- Patel S, Rosenkranz L, Hooks B, Tarnasky P, Raijman I, Fishman et al: Holmium-yttrium aluminum garnet laser lithotripsy in the treatment of biliary calculi using single-operator cholangioscopy: a multicenter experience (with video). Gastrointest Endosc 2014; 79: 344–348.
- Wong JC, Tang RS, Teoh AY, Sung JJ, Lau JY: Efficacy and safety of novel digital single- operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones. Endosc Int Open 2017; 5:E54–E58.
- Attwell AR, Patel S, Kahaleh M, Raijman IL, Yen R, Shah RJ: ERCP with per-oral pancreatoscopy-guided laser lithotripsy for calcific chronic pancreatitis: a multicenter US experience. Gastrointest Endosc 2015; 82: 311–318.
- Leung JW, Chung SS: Electrohydraulic lithotripsy with peroral choledochoscopy. BMJ 1989; 299: 595–598.
- Lux G, Ell C, Hochberger J, Müller, Demling L: The first successful endoscopic retrograde laser lithotripsy of common bile duct stones in man using a pulsed neodymium-YAG laser. Endoscopy 1986; 18: 144–145.
- Das AK, Chiura DA, Conlin, Eschelman D, Bagley DH: Treatment of biliary calculi using holmium:yttrium aluminum garnet laser. Gastrointest Endosc 1998; 48: 207–209.
- Chen YK, Pleskow DK: SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65: 832–841.
- Pereira P, Vilas-Boas F, Peixoto A, Andrade P, Lopes J, Macedo G: How SpyGlassTM may impact endoscopic retrograde cholangiopancreatography practice and patient management. GE Port J Gastroenterol 2018; 25: 132–137.
- Laleman W, Verraes K, Van Steenbergen W, Cassiman D, Nevens F, Van der Merwe S, et al: Usefulness of the single-operator cholangioscopy system SpyGlass in biliary disease: a single-center prospective cohort study and aggregated review. Surg Endosc 2017; 31: 2223–2232.
- Brewer Gutierrez OI, Bekkali NLH, Raijman I, Sturgess R, Sejpal DV, Aridi HD, et al: Efficacy and safety of digital single-operator cholangioscopy for difficult biliary stones. Clin Gastroenterol Hepatol 2017, Epub ahead of print.
- Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al: Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383–393.
- Navaneethan U, Hasan MK, Kommaraju K, Zhu X, Hebert-Magee S, Hawes RH, et al: Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc 2016; 84: 649–655.
- Buxbaum J, Sahakian A, Ko C, Jayaram P, Lane C, Yu CY, et al: Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc 2018; 87: 1050–1060.
- Sethi A, Chen YK, Austin GL, Brown WR, Brauer BC, Fukami NN, et al: ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc 2011; 73: 251–256.
Article / Publication Details
Received: February 06, 2018
Accepted: March 16, 2018
Published online: May 16, 2018
Issue release date: March - April
Number of Print Pages: 9
Number of Figures: 2
Number of Tables: 3
ISSN: 2341-4545 (Print)
eISSN: 2387-1954 (Online)
For additional information: https://www.karger.com/PJG
References
- Canena J: Once upon a time a guideline was used for the evaluation of suspected choledocholithiasis: a fairy tale or a nightmare? GE Port J Gastroenterol 2018; 25: 6–9.
- Maydeo A, Kwek BEA, Bhandari S, Bapat M, Dhir V: Single-operator cholangioscopy-guided laser lithotripsy in patients with difficult biliary and pancreatic ductal stones (with videos). Gastrointest Endosc 2011; 74: 1308–1314.
- Patel S, Rosenkranz L, Hooks B, Tarnasky P, Raijman I, Fishman et al: Holmium-yttrium aluminum garnet laser lithotripsy in the treatment of biliary calculi using single-operator cholangioscopy: a multicenter experience (with video). Gastrointest Endosc 2014; 79: 344–348.
- Wong JC, Tang RS, Teoh AY, Sung JJ, Lau JY: Efficacy and safety of novel digital single- operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones. Endosc Int Open 2017; 5:E54–E58.
- Attwell AR, Patel S, Kahaleh M, Raijman IL, Yen R, Shah RJ: ERCP with per-oral pancreatoscopy-guided laser lithotripsy for calcific chronic pancreatitis: a multicenter US experience. Gastrointest Endosc 2015; 82: 311–318.
- Leung JW, Chung SS: Electrohydraulic lithotripsy with peroral choledochoscopy. BMJ 1989; 299: 595–598.
- Lux G, Ell C, Hochberger J, Müller, Demling L: The first successful endoscopic retrograde laser lithotripsy of common bile duct stones in man using a pulsed neodymium-YAG laser. Endoscopy 1986; 18: 144–145.
- Das AK, Chiura DA, Conlin, Eschelman D, Bagley DH: Treatment of biliary calculi using holmium:yttrium aluminum garnet laser. Gastrointest Endosc 1998; 48: 207–209.
- Chen YK, Pleskow DK: SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video). Gastrointest Endosc 2007; 65: 832–841.
- Pereira P, Vilas-Boas F, Peixoto A, Andrade P, Lopes J, Macedo G: How SpyGlassTM may impact endoscopic retrograde cholangiopancreatography practice and patient management. GE Port J Gastroenterol 2018; 25: 132–137.
- Laleman W, Verraes K, Van Steenbergen W, Cassiman D, Nevens F, Van der Merwe S, et al: Usefulness of the single-operator cholangioscopy system SpyGlass in biliary disease: a single-center prospective cohort study and aggregated review. Surg Endosc 2017; 31: 2223–2232.
- Brewer Gutierrez OI, Bekkali NLH, Raijman I, Sturgess R, Sejpal DV, Aridi HD, et al: Efficacy and safety of digital single-operator cholangioscopy for difficult biliary stones. Clin Gastroenterol Hepatol 2017, Epub ahead of print.
- Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al: Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383–393.
- Navaneethan U, Hasan MK, Kommaraju K, Zhu X, Hebert-Magee S, Hawes RH, et al: Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc 2016; 84: 649–655.
- Buxbaum J, Sahakian A, Ko C, Jayaram P, Lane C, Yu CY, et al: Randomized trial of cholangioscopy-guided laser lithotripsy versus conventional therapy for large bile duct stones (with videos). Gastrointest Endosc 2018; 87: 1050–1060.
- Sethi A, Chen YK, Austin GL, Brown WR, Brauer BC, Fukami NN, et al: ERCP with cholangiopancreatoscopy may be associated with higher rates of complications than ERCP alone: a single-center experience. Gastrointest Endosc 2011; 73: 251–256.
Open Access License / Drug Dosage / Disclaimer
This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
Get Permission
PubMed ID
J.C. and L.L. contributed equally to this manuscript.