Endoscopic management for difficult common bile duct (CBD) stones still presents a challenge for several reasons, including anatomic anomalies, patients’ individual conditions and stone features. In recent years, variable methods have emerged that have attributed to higher stone removal success rates, reduced cost and lower adverse events. In this review, we outline a stepwise approach in CBD stone management. As first line therapy, endoscopic sphincterotomy and large balloon dilation are recommended, due to a 30%-50% reduction of the use of mechanical lithotripsy. On the other hand, cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence. As discussed, findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions. Furthermore, we evaluate the management of CBD stones in various surgical altered anatomy (Billroth II, Roux-en-Y and Roux-en-Y gastric bypass). Moreover, we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use, rather than following a failed management option. In addition, we discuss the importance of dissecting other techniques, such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed. In conclusion, we recognize that endoscopic sphincterotomy and large balloon dilation, mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones, but emerging techniques are in rapid evolution with encouraging results.
Background and study aims COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19.
Patients and methods We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020.
Results We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP.
Conclusion The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.
interval in according to the recent guideline. Routine administration to all patients undergoing to ERCP is considered unnecessary unless cholangitis or immunosoppression is present or biliary drainage is predicted to be incomplete. All patients undergoing to ERCP should be administered prophylactic drugs such as rectal indomethacin or diclofenac because of consistently reduced risk of post ERCP pancreatitis according to several meta-analysis and ESGE guideline. Endoscopic treatment is based on selective incannulation of the CBD and performing adequate endoscopic sphincterotomy. In case of failed biliary access several reasonable options could be chosen. CBD stone can be removed with either a basket or a balloon catheter in 85-90% of cases and the choice of the better device depends on common bile duct and stone size. Approximately 10-15% of biliary stone are difficult to extract and several technique, such as EPBD, PBSD and ML can be used. Alternative modality for the fragmentation of refractory CBD stone are intraductal lithotripsy (eg. Laser or Electrohydraulic lithotripsy) and ESWL. Mirizzi syndrome is usually treated by surgery although although there have been case reports of endoscopic removal. Intrahepatic stones are treated by dormia basket on guidewire after balloon dilation if stricture is present, or cholangioscopy with intraductal lithotripsy, per-oral cholangioscopic lithotripsy (POCSL) or percutaneous transhepatic cholangioscopy lithotripsy (PTCSL) and surgical resection (Hepatectomy). POCSL and PTCSL are hindered by high rates of stone recurrence. Biliary stenting as definitive treatment of difficult bile duct stone should be reserved for patients with short life expectancy. A review of case series suggest that BS is a safe and effective treatment for common bile duct stone in the pregnant patient but may be associated with higher risk of post ERCP pancreatitis than in the general population.
occurred in 8 (2.5%; moderate 5 patients, severe 3 patients). One patient had a shunt occlusion. Seventeen patients were in the HB group and 299 patients were in the No-HB group. The baseline characteristics were similar between both groups. There was no statistically significant difference in the rate of delayed bleeding (13% in the HB group vs. 2% in the No-HB group, p Z 0.06). However, in the secondary outcome, the multivariate analysis showed that HB therapy was an independent risk factor for delayed bleeding (odds ratio, 7.16; 95% confidence interval, 1.29-39.6; p Z 0.02). Conclusion: HB therapy in patients treated with oral antithrombotic therapy was associated with an increased risk of delayed bleeding after endoscopic treatment for CBD stone.
Background and aims:Restarting activity in Endoscopic Departments (ED) after COVID-19 lockdown raises critical issues. This survey investigates strategies and uncertainties on resumption of elective activity.Methods: Directors of 55 EDs in Northern Italy received a questionnaire focusing on the impact of pandemic on activity and organization and on the resources available at re-opening. A section was devoted to gather forecasts and proposals on the return path to normality.Results: All centres had reduced their activities of at least 50% of the pre-COVID-19 period. A rate of endoscopists (13.6%), nurses (25.2%), and health assistants (14%) were not available since infected, or relocated to other departments. One third of endoscopic rooms were converted to COVID-19 care. Two third had the waiting or the recovery areas too small for distancing. A dedicated pathway for infected patients could not be guaranteed in 20% of EDs. Only one third of EDs judged realistic to completely restore a pre-crisis workload by the next months. Optimizing appropriateness of procedures, closer interaction with GPs and triaging patients with telemedicine were the proposals to re-open EDs.
Conclusions:The critical issues while re-opening EDs calls for reducing the workload in the endoscopy units through appropriate rescheduling of procedures.
Funding: None
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