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• W2800838057 abstract "Following endoscopic sphincterotomy (ES), 80–90% of common bile duct stones can be removed using either a basket or a balloon catheter. However, there are several factors that determine when conventional endoscopic treatment is not preferred, such as surgically altered anatomy, character of stones, location of stones, and patients’ condition.1 During the pancreatobiliary session at the Annual Meeting of Endoscopic Forum Japan (EFJ) 2017, we discussed the current trends of endoscopic management of difficult bile duct stones in Japan, especially in cases with large stones and with surgically altered anatomy. Ichiro Yasuda (Teikyo University Mizonokuchi Hospital) and Shomei Ryozawa (Saitama Medical University International Medical Center) administered the questionnaires and moderated the discussions. Endoscopists from eight Japanese high-volume centers participated by answering the questionnaires and engaging in discussions. The participating doctors and their affiliations were as follows: Yosuke Nakai (The University of Tokyo), Harutoshi Sugiyama (Chiba University), Kazumichi Kawakubo (Hokkaido University), Ken Itou (Toho University Omori Medical Center), Takayoshi Tsuchiya (Tokyo Medical University), Takuji Iwashita (Gifu University), Yoshihide Kanno (Sendai City Medical Center), Yusuke Ishida (Kurume University). One foreign doctor, Bhavesh Kishor Doshi (National University Hospital Singapore) participated in the discussions. Before this meeting, we sent questionnaires to the participants at 10 institutions including the institutions of the two moderators. The questionnaires contained items about preference for first-line treatment, devices, salvage techniques etc. All participants responded to the questionnaires. The first question was regarding the definition of a large stone. The term “large stone” used here is defined as stones that cannot be successfully removed using endoscopic stone removal methods, or stones that require unsuitable and additional treatments. Most endoscopists regard a stone size of 12 mm or more in diameter as a “large stone” (Fig. 1). The scope shaft of duodenoscopes that are most often used (TJF260V/JF260V; Olympus, Tokyo, Japan) is 11.3 mm in diameter. Comparison of stone size with the scope shaft on the cholangiogram during endoscopic retrograde cholangiopancreatography (ERCP) was done. Traditionally, a mechanical lithotriptor was routinely used following ES. However, only one endoscopist still carried out this conventional technique. Other endoscopists carried out endoscopic papillary large balloon dilation (EPLBD) routinely or selectively prior to stone removal with or without mechanical lithotripsy (Fig. 2). Prior to EPLBD, seven of 10 endoscopists carried out ES, whereas the remaining three endoscopists did not carry out ES (Fig. 3). After initial treatment failure, all doctors chose peroral cholangioscopy (POCS)-guided laser or electrohydraulic lithotripsy (EHL) as a salvage treatment (Fig. 4). However, five endoscopists also used extracorporeal shock-wave lithotripsy (ESWL), depending on the situation. Previously, the endoscopic approach was thought to be challenging in patients with surgically altered anatomy, especially with difficult Billroth II (B-II) and Roux-en-Y (R-Y) reconstruction. However, balloon-assisted enteroscopes have dramatically changed the situation. All 10 endoscopists selected the endoscopic approach. None selected the percutaneous transhepatic approach. Six endoscopists selected the short-type single-balloon endoscope (SBE), whereas four selected the short-type double-balloon endoscope (DBE) (Fig. 5). Five endoscopists selected balloon enteroscopes (BE), whereas two selected a conventional gastroscope, two selected a colonoscope, and one selected an anterior oblique-viewing endoscope (Fig. 6). Six endoscopists preferred endoscopic papillary balloon dilation (EPBD) or EPLBD without ES, whereas four preferred ES or EPBD or EPLBD with ES depending on the situation (Fig. 7). After endoscopic approach failure, six endoscopists chose the endoscopic ultrasound (EUS)-guided approach, whereas four chose the percutaneous transhepatic approach (Fig. 8). Large stones need to be fragmented before removal. Mechanical lithotriptor (ML) is usually used following ES for fragmenting large stones. The reported success rate for stone clearance using ML is 84–98%.1 However, repeated cannulation into the bile duct is required to remove stone fragments after using ML. Therefore, the procedure is somewhat cumbersome. To overcome this problem, EPLBD is preferable compared to conventional ES for treating large stones. EPLBD can open the biliary orifice wider and it can reduce the need for ML. It can also shorten procedure and fluoroscopy times, and minimize adverse events associated with prolonged lithotripsy procedures.2, 3 However, EPLBD is not recommended for patients with obvious stricture of the distal bile duct and without bile duct dilation. Such patients are thought to be at an increased risk of perforation resulting from dilation of the bile duct by EPLBD. Original techniques included small incision (small ES) prior to EPLBD. However, some endoscopists have abandoned preliminary ES. Recently, some studies showed similar effectiveness and safety between EPLBD with and without prior ES.3, 4 However, there is insufficient evidence based on the results of studies. It is still under debate whether preliminary ES is necessary. Most endoscopists choose POCS-guided lithotripsy using laser or EHL probes as a reliable procedure for salvage treatments after failed conventional treatment. Currently, three types of POCS are available. The traditional POCS method involves a mother–baby system, in which a baby cholangioscope is inserted through the instrument channel of the mother duodenoscope. Lithotripsy can be done using a laser or EHL probe to direct endoscopic visualization. However, this system requires excellent coordination of two experienced endoscopists. In addition, the fragility and impaired steerability (only two-way steerability) of the equipment limits its popularity. A newly developed POCS system, the SpyGlass™ system (Boston Scientific, Natick, MA, USA), was designed to overcome some of these limitations. The POCS system can be operated by a single endoscopist. The four-way steerability provides improved maneuverability as compared to conventional cholangioscopes, and the independent irrigation channels are also helpful for maintaining a clear cholangioscopic field during the procedure. Most recently, the new SpyGlass™ system (SpyGlass™ DS) with higher-resolution integrated digital imaging and 60% wider field of view compared to the legacy model was newly developed. Some reports have already shown its efficacy with complete ductal clearance of 74–94% after failed conventional endoscopic lithotripsy.5, 6 The remaining type of POCS is direct POCS using an ultraslim upper endoscope. Feasibility and efficacy of direct POCS have also been evaluated. Successful treatment rate was reported in 85–89% of difficult bile stones cases.7, 8 Extracorporeal shock-wave lithotripsy is also a viable option for cases refractory to conventional endoscopic treatments. It can be attempted regardless of stone size. However, its efficacy appears to be decreased compared to POCS-guided lithotripsy.9 Therefore, the application of ESWL may be limited in cases with unsuitable for or after failed POCS-guided lithotripsy or at institutions where POCS-guided lithotripsy is unavailable. The endoscopic approach in patients with surgically altered anatomy is often challenging, and is usually associated with limited success. In patients with Billroth-I reconstruction, a conventional duodenoscope can reach the papilla and ES can be similarly carried out for patients with normal anatomy. In patients with B-II reconstruction, conventional gastroscope, colonoscope and duodenoscope are used; however, the usefulness of anterior oblique-viewing endoscope has also been reported.10 In patients with difficult B-II cases and R-Y cases, the long and angulated afferent loop can make it technically more difficult to reach the papilla. Recently, the usefulness of SBE or DBE has been reported for the endoscopic approach in patients with difficult B-II and R-Y.11 Even if the papilla is reached, the papilla will have to be approached through the anal side, and thus ES can be extremely difficult. In ES for patients with B-II and R-Y, cutting can be carried out using a push type or specialized sphincterotome otherwise, cutting can be done using a needle knife after placement of a biliary stent. EPBD and EPLBD appear to be easy to carry out and reduce the risk of bleeding and perforation. Recently, several EUS-guided biliary access techniques have been introduced. The EUS-guided antegrade technique can be carried out in patients with surgically altered anatomy. In this technique, the left intrahepatic bile duct is initially punctured, and a guidewire is inserted into the duodenum. The puncture tract is then dilated using a dilation catheter and the bile duct stone is pushed out using a retrieval balloon catheter into the duodenum after antegrade papillary balloon dilation.1 Authors declare no conflicts of interest for this article." @default.
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• W2800838057 title "Current strategies for the endoscopic management of difficult-to-treat bile duct stones in Japan" @default.
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