Endoscopic Management of Bile Duct Stones

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Endoscopic Management of Bile Duct Stones
Stuart Sherman, M.D. Glen A. Lehman Professor of
Gastroenterology Department of Medicine Indiana
University Medical School Clinical Director,
Gastroenterology and Hepatology Division Director
of ERCP Indiana University Medical
CenterIndianapolis, Indiana
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Standard Techniques of Stone Extraction

• Endoscopic sphincterotomy tailor length to size
  of stone
• Larger incisions may have lower rates of late
  restenosis
• Balloon catheter
• Dormia basket

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Stone Retrieval Instruments
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Stone Removal
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Stone Removal
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Stone Retrieval Techniques
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Success and Complication Rates of ES/Stone
Removal for Bile Duct Stones
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Balloon Dilation
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Endoscopic Papillary Balloon Dilation (EPBD)

• ES is successful, why another technique?
• EPBD has potential advantages over ES
• Avoids short-term complications of bleeding and
  perforation
• Preserves biliary sphincter function and may
  reduce long-term sequelae associated with ES (ES
  stenosis, cholangitis, recurrent stones)
• How do ES and EPBD Compare?

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ES vs. EPBD Meta-Analysis (8 RCT, 1106
patients)
Am J Gastroenterol 2004991455
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Comments About Meta-Analysis

• Theoretical benefit of preserving sphincter
  function not assessed
• Procedure likely more time-consuming, technically
  difficult and costly because of more frequent
  need for mechanical lithotripsy and rescue ES
• Some studies excluded patients with too many
  stones or if bile duct diameters were too big
• Meta-analysis did not include results of US
  multicenter study

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US Multicenter Study ES vs. EPBD
Gastro 20041271291
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When is EPBD Indicated for Bile Duct Stone Rx

• Child-Pugh C cirrhosis with coagulopathy (plt
  lt80,000 INR lt50 normal)
• Bleed 5/14 after ES 3 deaths
• Billroth II anatomy
• RCT of ES vs. EPBD ES associated with
  significantly higher bleeding rate 17 vs. 2
  p 0.034

Park GIE 200460180 Bergman GIE 20015319
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Reasons for Failed Duct Clearance

• Difficult access to the papilla
• Unsuccessful cannulation
• Inadequate sphincterotomy
• Unsuccessful extraction
• Inadequate access to stone

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The Large CBD Stone

• Most commonly refers to a stone gt 15 mm in
  diameter
• Rare to be able to make ES larger than 15 mm
• Stones lt 15 mm in diameter may be considered
  large if
• Proximal to stricture/narrow intrapancreatic
  segment
• Impacted
• Intrahepatic
• ES length is limited e.g., periampullary
  diverticulum

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Stones Above Stricture
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Stones Above Stricture
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(No Transcript)
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Mirizzis Syndrome
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Intrahepatic Stones
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Intrahepatic Stones
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Bile Duct Stone
- Stent
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Endoscopic Management of Large Bile Duct Stones

• Mechanical lithotripsy
• Intraductal shockwave lithotripsy
• Electrohydraulic
• Laser
• Extracorporeal shockwave lithotripsy (ESWL)
• Dissolution
• MTBE
• Monooctanoin
• Long term stents

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Mechanical Lithotripsy

• Simplest endoscopic adjunct for manage- ment of
  large stones not removed by standard balloon
  catheters and baskets
• Mechanical forces used to crush stone against
  metal sheath

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Mechanical Lithotripsy

• Soehendra type
• Stone captured
• Basket handle cut endoscope removed
• Metal sheath advanced over Dormia basket
• Crank handle turned bringing captured stone
  against metal sheath resulting in fragmentation
  or basket wire breakage
• Particularly useful for basket impaction
• Through-the-scope model
• Three layer system basket, inner plastic sheath,
  outer metal sheath
• Stone capture while metal sheath in endoscope
  channel
• Metal sheath advanced and stone crushed against it

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Soehendra Mechanical Lithotriptor
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Mechanical Lithotripsy
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Mechanical Lithotripsy
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Mechanical Lithotripsy

• Advantages
• Relatively easy to use
• Relatively low cost
• Prevents stone impaction
• Can be done at initial ERCP
• Disadvantages
• Requires stone capture
• Very hard stones may not fragment
• Several baskets may be required for each patient

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Mechanical Lithotripsy For Bile Duct Stones (7
Studies)
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Bile Duct Stones
Failed Mechanical Lithotripsy
Mother/Baby - Laser - EHL
Dissolve
Stent
Surgery
Percutaneously
ESWL
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Contact Dissolution Therapy

• Search for a rapidly effective, readily
  available, solvent remains elusive
• Usually infused through NBT or T-tube
• Monooctanoin, only FDA approved agent for bile
  duct stone use. Dissolution in 54 of 343
  patients during a mean of 7 days
• Methyl-tert-butyl ether (MTBE) excellent
  cholesterol solvent but in clinical practice only
  modest efficacy noted with a significant
  complication rate
• No longer used

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Extracorporeal Shockwave Lithotripsy (ESWL)

• Acoustic energy waves fragment stones
• ESWL machines are available in many centers
  (urologic applications)
• Fragmentation rates 80 - 95
• Complete stone clearance in 80 usually
  requires a number of ESWL and endoscopic sessions

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Intraductal Shockwave Lithotripsy

• Best performed by direct vision using mother-baby
  scope system
• Procedure is cumbersome and requires two skilled
  endoscopists
• Both laser and electrohydraulic lithotriptors are
  effective in fragmenting gt 90 of stones with
  duct clearance in 80-90
• Risk of bile duct injury with electrohydraulic
  lithotripsy is substantial

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Mother-Baby Scope System
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Historical Barriers to Cholangioscopy
Direct visualization of the pancreaticobiliary
system for diagnosis and therapy has not been
widely applied in clinical practice because of
technical and technological limitations.
Requires two operators
Limited two-way steering capability
No dedicated irrigation channels
Scope fragility and high repair costs
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New Technology SpyGlass!
SpyGlass Platform Features
Single-operator system
Four-way steering capability
Independent irrigation channels
Diagnostic and therapeutic capabilities
Disposable and multi-use components
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Electro-Hydraulic Lithotripsy
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Bile Duct Stone
- Stent
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Stenting vs. Urso Stenting for Defiant CBD
Stones
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Number with complete duct clearance
n 10 0
n 9
Control
UDCA
Gastrointest Endosc 199339530
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Long-Term Stents for Unextractable BD Stones

• Initial reports 12-15 late complications,
  primarily cholangitis
• Bergman reported 34 complications in 23 of 58
  patients (40) and 9 (16) biliary-related deaths
  stented for a median of 36 months
• Permanent stenting should be restricted to
  patient unfit for elective surgical, endoscopic,
  or percutaneous treatments and in those with
  short life expectancy

GIE 199542195
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Balloon Dilation and Stone Extraction
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Stone Removal with ES Large Diameter Balloon
Dilator (12-20 mm) after failed Standard
Techniques (6 studies 2003-2007)
Endoscopy 2007
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Conclusions

• Endoscopic removal of BD stones is successful in
  80-90 using standard balloons and baskets
• Stone location, stone size, and bile duct
  features may render stones unextractable using
  standard stone retrieval techniques
• A number of options available for unextractable
  stones but mechanical lithotripsy is cheapest and
  easiest if stone can be captured in basket
• Intracorporeal and extracorporeal lithotripsy
  techniques have a high success rate
• Using all endoscopic and ancillary techniques,
  stone clearance rate should be gt 97