International Session（Symposium）10(JGES・JSGE・JSGS・JSGCS)
Sat. November 7th   14:30 - 17:00   Room 11: Portopia Hotel South Wing Topaz
IS-S10-2_E
 Endoscopic treatment of difficult biliary & pancreatic stones
Amit Maydeo
Baldota Institute of Digestive Sciences, Global Hospital
The Hepato-pancreato-biliary system is one of the most complicated areas of the human body. Stones which occur in the bile duct or pancreatic duct present either with pain, jaundice, fever, weight loss or diabetes. The first advance in endoscopic therapy was initiated with the invention of biliary sphincterotomy in 1974 by Kawai and Classen simultaneously.
In patients who have small stones in the bile duct with a dilated duct, removal by an ERCP is quite simple by only doing a biliary sphincterotomy. In most patients of bile duct stones however, we need to use some form of a basket or balloon to extract them. Using baskets or balloons, more than 80% of the bile duct stones can be extracted. In 10% to 15% of the times however, the bile duct stones are categorized as difficult stones. These are stones which are large, hard, impacted, square shaped, situated above strictures, forming a stone conglomerate, intrahepatic or in those where there is a stone to duct discrepancy.
For these difficult stones, we have a variety of endoscopy accessories which we can use like mechanical lithotriptors, dilatation balloons, extracorporeal shock wave machines or even intra ductal EHL or LASER. Stone which are in the form of conglomerate are best removed using a wire guided dormia basket with multiple sweeps. Stones which are large and hard but not too many or impacted can be removed using the technique of mechanical lithotripsy. Another technique which is now more commonly used instead of mechanical lithotripsy is large balloon dilatation of the lower bile duct and ampulla called as balloon sphincteroplasty. In stones which are impacted, too many or intrahepatic, we can also use the technique of ESWL after placing inside a naso-biliary catheter. . The most effective method to remove the really difficult stones in the bile duct is to use intra-ductal lithotripsy with a cholangioscope and LASER or EHL. Using the cholangioscope, even remnant stones in the cystic duct remnant can be removed with a high degree of success.
Pancreatic stones are more difficult to remove than bile duct stones mainly because they are hard, spiculated, usually multiple, usually impacted, situated behind strictures and can be associated with complex pancreatic disease. Small pancreatic duct stones in dilated ducts can be remove easily using the same technique as for bile duct stones using either dormia baskets or balloons. Large pancreatic stones too if they are radio-lucent can be removed without crushing them. For this the technique of large balloon dilatation of the pancreatic sphincter is done upto 12 mm and then we can achieve a complete ductal clearance.
In most of the pancreatic stones which are radio-opaque, a pre-ERCP crushing is required for removal. This is done using extracorporeal shock wave lithotripsy or ESWL. Multiple sessions of low intensity ESWL sessions are given until the stones are pulverized into less than 3mm fragments. Only then an ERCP can be performed to achieve a satisfactory ductal clearance. In some situations where the stone fragments are firmly impacted, a passage can be created using a Soehendra stent retriever device over a guide wire.
In some suitable situations, we can also use pancreaticoscopy with LASER for shooting and pulverizing the stones in the pancreatic duct before extraction. In some suitable situations, we can also use pancreaticoscopy with LASER for shooting and pulverizing the stones in the pancreatic duct before extraction.
Index Term 1: Bile duct stones
Index Term 2: Pancreatic duct stones
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