scholarly journals Clinical Application of a Single-Operator Direct Visualization System Improves the Diagnostic and Therapeutic Yield of Endoscopic Retrograde Cholangiopancreatography

2013 ◽  
Vol 27 (1) ◽  
pp. 15-19 ◽  
Author(s):  
Turki AlAmeel ◽  
Vincent Bain ◽  
Gurpal Sandha
Keyword(s):  
Clinical Utility ◽  
Biliary Tree ◽  
Biliary Disease ◽  
Biliary Strictures ◽  
Biliary Stones ◽  
Visualization System ◽  
Operator Experience ◽  
Electrohydraulic Lithotripsy ◽  
Single Operator ◽  
Biliary Pathology

BACKGROUND: Single-operator cholangioscopy enables direct diagnostic visualization and therapeutic intervention in the biliary tree. There is increasing evidence of its clinical utility in the assessment of biliary strictures and treatment of difficult stones.OBJECTIVE: To describe the first reported Canadian experience with managing biliary disease using single-operator cholangioscopy.METHODS: The present study was a retrospective analysis of data collected from all sequential patients undergoing single-operator cholangioscopy for assessment of biliary strictures and treatment of biliary stones. The main outcome measures were the ability to make an overall diagnosis of stricture (based on visual appearances and tissue histology), and to fragment and extract biliary stones.RESULTS: Thirty patients (17 women), mean age 66 years (range 41 to 89 years) underwent single-operator cholangioscopy. In biliary strictures (20 patients), overall accuracy for visual and tissue diagnosis was 84% and 81%, respectively. Successful electrohydraulic lithotripsy with stone clearance was achieved in 90% of the 10 patients who failed previous conventional therapy. The mean (± SD) procedure time was 61±21 min (range 20 min to 119 min). One patient developed mild postendoscopic retrograde cholangioscopy pancreatitis.CONCLUSION: The results of this experience reaffirms the clinical utility and safety of single-operator cholangioscopy for the management of biliary pathology. Further improvements can be achieved with increasing operator experience and refinements in optical technology.

scholarly journals Difficult Biliary Stones: A Comprehensive Review of New and Old Lithotripsy Techniques

Medicina ◽  
2022 ◽  
Vol 58 (1) ◽  
pp. 120
Author(s):  
Edoardo Troncone ◽  
Michelangela Mossa ◽  
Pasquale De Vico ◽  
Giovanni Monteleone ◽  
Giovanna Del Vecchio Blanco
Keyword(s):  
Balloon Dilation ◽  
Common Bile Duct Stones ◽  
Endoscopic Management ◽  
Stone Extraction ◽  
Biliary Stones ◽  
Electrohydraulic Lithotripsy ◽  
Biliary Sphincterotomy ◽  
Single Operator ◽  
Large Balloon ◽  
Large Balloon Dilation

Biliary stones represent the most common indication for therapeutic endoscopic retrograde cholangiopancreatography. Many cases are successfully managed with biliary sphincterotomy and stone extraction with balloon or basket catheters. However, more complex conditions secondary to the specific features of stones, the biliary tract, or patient’s needs could make the stone extraction with the standard techniques difficult. Traditionally, mechanical lithotripsy with baskets has been reported as a safe and effective technique to achieve stone clearance. More recently, the increasing use of endoscopic papillary large balloon dilation and the diffusion of single-operator cholangioscopy with laser or electrohydraulic lithotripsy have brought new, safe, and effective therapeutic possibilities to the management of such challenging cases. We here summarize the available evidence about the endoscopic management of difficult common bile duct stones and discuss current indications of different lithotripsy techniques.

scholarly journals A274 EARLY SINGLE-OPERATOR CHOLANGIOSCOPY ASSISTED ELECTROHYDRAULIC LITHOTRIPSY (SOC-EHL) IN THE MANAGEMENT OF DIFFICULT BILIARY STONES IS COST-EFFECTIVE WHEN COMPARED TO A DELAYED STEP-UP APPROACH TO LATER SOC-EHL

2020 ◽  
Vol 3 (Supplement_1) ◽  
pp. 151-152
Author(s):  
S Alrajhi ◽  
A N Barkun ◽  
V Adam ◽  
K Callichurn ◽  
M Martel ◽  
...  
Keyword(s):  
Cost Effective ◽  
Standard Of Care ◽  
Dominant Strategy ◽  
Sensitivity Analyses ◽  
Optimal Timing ◽  
Health State ◽  
Biliary Stones ◽  
Cbd Stones ◽  
Electrohydraulic Lithotripsy ◽  
Single Operator

Abstract Background Single-operator cholangioscopy assisted electrohydraulic lithotripsy is the standard of care for difficult common bile duct (CBD) stones with failed clearance using standard ERCP. This technology is expensive and optimal timing of its use in terms of cost-effectiveness in the management algorithm of patients with difficult CBD stones remains unclear Aims To determine the cost-effective timing of SOC-EHL utilization in the management of difficult CBD stones Methods A decision model was developed assessing 4 strategies and progressively delayed introduction of SOC-EHL in relation to ERCP over 6-months. Difficult stones were defined as having failed CBD clearance via standard ERCP. Probability estimates for each health state were obtained from a literature systematic review. For each strategy, outpatients undergoing ERCP underwent different timings of SOC-EHL introduction from the first to the fourth ERCP and were followed for subsequent need for re-intervention, adverse events, need for surgery, and/or successful endoscopic CBD clearance. The unit of effectiveness was complete CBD clearance without need for surgery. Deterministic sensitivity analyses were performed varying all 50 model variables across ranges spanning 30% of their respective values. Costs are in 2018US$ based on US data. Results Performing SOC-EHL immediately during the first ERCP is the least expensive approach when compared to delaying SOC-EHL. This strategy costs $15,528 on average per patient with CBD clearance avoiding surgery and can save between $260 to $720 compared to the 3 other strategies, which introduce SOC-EHL during the second to the fourth ERCP. Effectiveness is clinically comparable between the four strategies ranging from 97–99%. Deterministic sensitivity analysis shows changes in the results when the ERCP complication rate (baseline probability of 6%) decreases to 4.5%, when the SOC-EHL (baseline costs of $2,450) costs more than $2,670, or when the ERCP facility fees (baseline costs of $4,292) are less than $3,425. In all 3 scenarios, delaying the first SOC-EHL use to the fourth procedural attempt becomes the dominant strategy. Variations of the other 47 variables did not alter results. Conclusions Although SOC-EHL is expensive, this analysis demonstrates that among patients who have failed a prior attempt at stone extraction, utilization of SOC-EHL at the next (first subsequent) ERCP is less costly when compared to its delayed introduction. However, postponing the use of SOC-EHL to the fourth ERCP could be identified as the most cost-effective strategy when facility fees or ERCP complications rates are below certain thresholds, or when the costs of SOC-EHL extend beyond a defined threshold. Funding Agencies None

scholarly journals Clinical impact of digital cholangioscopy in management of indeterminate biliary strictures and complex biliary stones: a single-center study

2019 ◽  
Vol 12 ◽  
pp. 263177451985316 ◽  
Author(s):  
Stephanie Yan ◽  
Sooraj Tejaswi
Keyword(s):  
Primary Sclerosing Cholangitis ◽  
Patient Outcomes ◽  
Sclerosing Cholangitis ◽  
Patient Characteristics ◽  
Clinical Impact ◽  
Endoscopic Management ◽  
Biliary Strictures ◽  
Brush Cytology ◽  
Biliary Stones ◽  
Single Operator

Aims: Endoscopic management of indeterminate strictures and complex stones remains a challenge, for which the latest generation single-operator digital cholangioscope (SpyGlass DS) has shown promising results. We aimed to study the clinical impact of single-operator digital cholangioscope at our tertiary academic center. Methods: We retrospectively reviewed all digital cholangioscopies performed from June 2015 to May 2018. Patient characteristics, procedure characteristics, and post-procedural patient outcomes were recorded. Results: A total of 50 patients (26 men, average age 61.4 years) underwent 67 procedures. Indications were biliary stones (21/50, 42%), strictures and primary sclerosing cholangitis surveillance (22/50, 46%), and miscellaneous (7/50, 14%). The average procedure time was 82 ± 29 min (99.5 min for stones and 74.2 min for strictures). Stone clearance was achieved in 19/21 (90.47%) cases, with electrohydraulic lithotripsy employed in 16/21 and repeat cholangioscopy necessary in 9/21. Malignant strictures (10) were differentiated from benign (12) in all cases both in patients with primary sclerosing cholangitis (9) and in those without (13), based on visual cholangioscopic features (sensitivity and specificity 100%), single-operator digital cholangioscope–directed biopsies (sensitivity 60% and specificity 100%), and brush cytology (sensitivity 37.5% and specificity 100%). Complications included one post-sphincterotomy bleeding and one post-procedural cholangitis despite antibiotic prophylaxis, but no procedure-related mortality. Conclusion: Single-operator digital cholangioscope had a high success rate and a low rate of complications for management of indeterminate strictures and difficult biliary stones. Visual cholangioscopic features of biliary strictures had excellent diagnostic accuracy, and targeted biopsies outperformed brush cytology. Early implementation of cholangioscopy for select indications leads to successful patient outcomes and reduces diagnostic delays, cost, and risks of repeat endoscopic retrograde cholangiopancreatographies.

scholarly journals Interobserver Agreement for Single Operator Choledochoscopy Imaging: Can We Do Better?

2014 ◽  
Vol 2014 ◽  
pp. 1-4 ◽  
Author(s):  
Amrita Sethi ◽  
Theodore Doukides ◽  
Divyesh V. Sejpal ◽  
Douglas K. Pleskow ◽  
Adam Slivka ◽  
...  
Keyword(s):  
Interobserver Agreement ◽  
Final Diagnosis ◽  
Boston Scientific ◽  
Direct Visualization ◽  
Visualization System ◽  
Video Clips ◽  
Average Accuracy ◽  
Single Operator ◽  
Biliary Pathology ◽  
Spyglass Direct Visualization System

Background. The SpyGlass Direct Visualization System (Boston Scientific, Natick, MA) is routinely used during single operator choledochoscopy (SOC) to identify biliary lesions or strictures with a diagnostic accuracy up to 88%. The objective of this study was to determine the interobserver agreement (IOA) of modified scoring criteria for diagnosing biliary lesions/strictures. Methods. 27 SPY SOC video clips were reviewed and scored by 9 interventional endoscopists based on published criteria that included the presence and severity of surface structure, vasculature visualization, lesions, and findings. Results. Overall IOA was “slight” for all variables. The K statistics are as follows: surface (K=0.12, SE = 0.02); vessels (K=0.14, SE = 0.02); lesions (K=0.11, SE = 0.02); findings (K=0.08, SE = 0.03); and final diagnosis (K=0.08, SE = 0.02). The IOA for “findings” and “final diagnosis” was also only “slight.” The final diagnosis was malignant (11), benign (11), and indeterminate (5). Conclusion. IOA using the modified criteria of SOC images was slight to almost poor. The average accuracy was less than 50%. These findings reaffirm that imaging criteria for benign and malignant biliary pathology need to be formally established and validated.

scholarly journals Early cholangioscopy-assisted electrohydraulic lithotripsy in difficult biliary stones is cost-effective

2021 ◽  
Vol 14 ◽  
pp. 175628482110313
Author(s):  
Saad Alrajhi ◽  
Alan Barkun ◽  
Viviane Adam ◽  
Kashi Callichurn ◽  
Myriam Martel ◽  
...  
Keyword(s):  
Cost Effective ◽  
Sensitivity Analyses ◽  
Optimal Timing ◽  
Biliary Stones ◽  
Electrohydraulic Lithotripsy ◽  
Effectiveness Model ◽  
Probability Estimates ◽  
Patient Pathways ◽  
Single Operator ◽  
Optimal Approach

Background and Aims: Single-operator cholangioscopy-assisted electrohydraulic lithotripsy (SOC-EHL) is effective and safe in difficult choledocholithiasis. The optimal timing of SOC-EHL use, however, in refractory stones has not been elucidated. The following aims to determine the most cost-effective timing of SOC-EHL introduction in the management of choledocholithiasis. Methods: A cost-effectiveness model was developed assessing three strategies with a progressively delayed introduction of SOC-EHL. Probability estimates of patient pathways were obtained from a systematic review. The unit of effectiveness is complete ductal clearance without need for surgery. Cost is expressed in 2018 US dollars and stem from outpatient US databases. Results: The three strategies achieved comparable ductal clearance rates ranging from 97.3% to 99.7%. The least expensive strategy is to perform SOC-EHL during the first endoscopic retrograde cholangiography pancreatography (ERCP) (SOC-1: 18,506$). The strategy of postponing the use of SOC-EHL to the third ERCP (SOC-3) is more expensive (US$18,895) but is 2% more effective. (0.9967). SOC-EHL during the second ERCP in the model (SOC-2) is the least cost-effective. Sensitivity analyses show altered conclusions according to the cost of SOC-EHL, effectiveness of conventional ERCP, and altered willingness-to-pay (WTP) thresholds with early SOC-1 being the most optimal approach below a WTP cut-off of US$20,295. Conclusions: Early utilization of SOC-EHL (SOC-1) in difficult choledocholithiasis may be the least costly strategy with an effectiveness approximating those achieved with a delayed approach where one or more conventional ERCP(s) are reattempted prior to SOC-EHL introduction.

scholarly journals CHOLANGIOSCOPY IN BILE DUCT DISEASE: a case series

2014 ◽  
Vol 51 (3) ◽  
pp. 250-254 ◽  
Author(s):  
Eduardo Guimarães Hourneaux de MOURA ◽  
Tomazo FRANZINI ◽  
Renata Nobre MOURA ◽  
Fred Olavo Aragão Andrade CARNEIRO ◽  
Everson Luiz de Almeida ARTIFON ◽  
...  
Keyword(s):  
Bile Duct ◽  
Balloon Dilation ◽  
Case Series ◽  
Therapeutic Endoscopy ◽  
Duodenal Perforation ◽  
Biliary Strictures ◽  
Electrohydraulic Lithotripsy ◽  
Single Operator ◽  
Large Bile Duct ◽  
Bile Duct Disease

Context Direct endoscopic visualization of biliopancreatic duct is certainly one of the greatest advances of therapeutic endoscopy. The use of a single-operator cholangioscopy platform (SpyGlass) is a promising technique in the evaluation of diseases such as indeterminate biliary stricture and giant choledocholitiasis. This is the first Brazilian case series using this technology. Methods We report a case series of 20 patients in whom SpyGlass was used with diagnostic and therapeutic intention. Results Most patients were female (60%) and the median age was 48 years (ranging from 14 to 94). Choledocholitiasis was the most common indication (12/20), and electrohydraulic lithotripsy was applied in eight (66%). Electrohydraulic lithotripsy was successful in seven (87.5%) patients. Partial stone fragmentation occurred in one patient with large stone causing stone-choledochal disproportion, which was conducted with biliary plastic stent placement and a second scheduled endoscopic approach in 3 months. In cases of undefined etiology of biliary strictures, it was possible to exclude malignancy due to direct visualization (7/8) or biopsy (1/8). One complication occurred (duodenal perforation) after papillary balloon dilation. Conclusion The use of SpyGlass demonstrated the benefits, especially in cases of large bile duct stones and indeterminate biliary strictures. Other potencial improvements such as reduction on radiation exposure should be confirmed in prospective studies.

scholarly journals Biliary stone extraction through T-tube tract using flexible fiberoptic choledochoscope

2019 ◽  
Vol 9 (2) ◽  
Author(s):  
Quan Anh Tuấn Lê
Keyword(s):  
Clearance Rate ◽  
Fiber Optic ◽  
Biliary Strictures ◽  
Stone Extraction ◽  
Biliary Stones ◽  
Biliary Stone ◽  
T Tube ◽  
Electrohydraulic Lithotripsy ◽  
Flexible Fiber ◽  
The Mean

Tóm tắt Đặt vấn đề: Còn sỏi sau mổ sỏi đường mật là một vấn đề thường gặp và là một vấn đề khó khăn đối với các phẫu thuật viên gan mật. Mục tiêu: Đánh giá hiệu quả của lấy sỏi mật qua đường hầm ống Kehr với ống soi mềm, kết hợp tán sỏi điện thủy lực. Phương pháp nghiên cứu: Nghiên cứu can thiệp, tiến cứu, không nhóm chứng. Chúng tôi sử dụng ống soi mềm đường mật 5mm, kết hợp với tán sỏi điện thủy lực. Kết quả: Từ tháng 01 năm 2010 đến tháng 01 năm 2013, chúng tôi thực hiện trên 164 bệnh nhân. Tuổi trung bình là 50. Tất cả các trường hợp (TH) đều có sỏi trong gan. Trong đó có 63 bệnh nhân có sỏi ống mật chủ kèm theo. Số lần lấy sỏi trung bình là 4,5 lần (từ 1 đến 10 lần). Có 139 TH (84,8%) phải tán sỏi điện thủy lực vì sỏi to hay dính chặt vào đường mật. Tỉ lệ hết sỏi sau khi lấy qua đường hầm ống Kehr trên cả 3 phương tiện bao gồm nội soi đường mật, siêu âm và X quang sau mổ là 90,9%. Nguyên nhân không lấy hết sỏi do đường mật nhỏ, gập góc hay có hẹp đường mật. Tỉ lệ hẹp đường mật là 34,8% (57 TH). Không có tai biến và biến chứng nặng. Thời gian nằm viện trung bình là 10 ngày. Kết luận: Lấy sỏi mật qua đường hầm ống Kehr kết hợp với tán sỏi điện thủy lực là cách giải quyết sỏi sót và sỏi đường mật trong gan rất hiệu quả và an toàn với tỉ lệ hết sỏi cao và không có biến chứng nặng. Đây là phương pháp tối ưu cho những bệnh nhân còn sỏi sau mổ có mang ống Kehr. Abstract Introduction: Retained biliary stones remain a common clinical problem in patients after surgery and a challenge for hepatobiliary surgeons. Objectives: The aim of this study is to evaluate the efficacy of biliary stone extraction via T-tube tract using a flexible fiber optic choledochoscope and electrohydraulic lithotripsy. Material and Methods: This is a prospective, interventional case series study. A 5mm flexible fiber optic choledochoscope was used in accompanied with electrohydraulic lithotripsy. Results: From January 2010 to January 2013, there were 164 included in this study. The mean age was 50. All of the patients had intrahepatic stones. Among them, 63 patients had common bile duct stones. Stone extractions on average were 4.5 (from 1 to 10 times). Electrohydraulic lithotripsy was necessary in 139 patients (84.8%) because of large or impacted stones. Complete clearance rate was 90.9% consisting of cholagioscopic, ultrasonographic and cholangioghaphic clearances. The most common factors related to failure of stone extraction are small associated with angulated intrahepatic bile ducts and biliary strictures. Biliary strictures were noticed in 57 patients (34.8%). There were no major accidents and complications. The mean hospital stay was 10 days. Conclusion: Biliary stone extraction via T-tube tract with electrohydraulic lithotripsy is a safe and efficient procedure for retained biliary stones and intra-hepatic stones with a high complete clearance rate and no major complications. This is the method of choice for treatment of retained biliary stones in patients with a T-tube in situ. Keywords: Biliary stone extraction, T tube tract.

Dye-Free Cannulation of the Biliary Tree: Outcomes in a Single Operator Experience of 800 Cases

2008 ◽  
Vol 67 (5) ◽  
pp. AB152
Author(s):  
Dharmendra Verma ◽  
Kristen Hilden ◽  
Romil Chadha ◽  
Kristen Thomas ◽  
Douglas G. Adler
Keyword(s):  
Biliary Tree ◽  
Operator Experience ◽  
Single Operator
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