Novel use of a balloon dilatation catheter to enable mechanical lithotripsy of difficult common bile duct stones after initial failed attempt: A case report.

INTRODUCTION: Difficult and large common bile duct stones can be crushed and removed using a mechanical lithotripter. Very often the lack of working space within the common bile duct causing the failure of mechanical lithotripsy would inevitably mean repeat or further invasive procedures. PRESENTATION OF CASE: A patient with large and multiple common bile duct stones underwent ERCP, and initial deployment of a mechanical lithotripter failed due to the lack of working space within the common bile duct. A through-the-scope (TTS) dilator was utilized to increase the working space before successful deployment of the mechanical lithotripter, and subsequent clearance of all stones within the same setting. DISCUSSION: We herein describe a novel and ingenious technique of utilizing a through-the-scope (TTS) dilator in helping to expand the space within the common bile duct to allow for full deployment of a mechanical lithotripter and successful clearance of common bile duct stones. This method can be easily applied by advanced endoscopists and is expected to lead to increased success rates of difficult common bile duct stones clearance in a single setting. CONCLUSION: Use of TTS dilators to increase working space within the common bile duct can be useful in increasing the success rates of mechanical lithotripsy in the setting of large and multiple common bile duct stones.

ERCP in patients with periampullary diverticulum.

BACKGROUND/AIMS: Duodenal diverticula, discovered incidentally in patients during endoscopic retrograde cholangiopancreatography, are usually asymptomatic, but can be the source of significant morbidity. The aim of this study was to evaluate the indications for endoscopic retrograde cholangiopancreatography, the course of this procedure and complications after this procedure in patients with periampullary diverticulum. METHODOLOGY: Clinical, laboratory, ultrasonographic, and endoscopic retrograde cholangiopancreatography data of 626 patients from a single endoscopy center were retrospectively analyzed. RESULTS: The periampullary diverticulum was identified in 72 patients (11.5%). The difficulty in cannulation of papilla of Vater was encountered in 57 patients (79.2%) with diverticulum compared to 54 patients (9.7%) without diverticulum (P < 0.001). Cannulation of common bile duct was successful in 592 patients (94.6%). Cannulation of common bile duct failed in 8 patients (11.1%) with diverticulum compared to 26 patients (4.7%) without diverticulum (P = 0.046). Patients without diverticulum (n = 168, 31.9%) had two-times more often dilated common bile duct > or = 6 mm without stone on ultrasound compared to patients with diverticulum (n = 12, 17.6%) (P = 0.017). Patients with diverticulum presented 1.8-times more often with retained stone in the common bile duct than patients without diverticulum (16.7% vs. 9.7%). 17.3% of patients developed post-endoscopic retrograde cholangiopancreatography complications, which did not significantly differ in both groups. However, the patients who presented with retained common bile duct stones had higher post-endoscopic retrograde cholangiopancreatography complications (P = 0.011). CONCLUSIONS: Cannulation of the common bile duct is more difficult in patients with periampullary diverticulum and requires more skills. Periampullary diverticulum is also associated with higher risk of retained stones in the common bile duct which may lead to higher post-endoscopic retrograde cholangiopancreatography complication rate.

Modified rendezvous technique in management of biliary leak in right lobe live donor liver transplant recipients.

Biliary complication is the Achilles' heel for live donor liver transplant. Bile leak is particularly difficult to manage as the anastomotic site was often angled acutely. We described a patient with bile leak managed by a modified rendezvous technique whereby the endoscopist and radiologist work simultaneously under fluoroscopy. Unlike the traditionally described rendezvous technique where the grasping of guidewire occurred at the duodenum, the grasping of guidewire occurred at the biloma in this modified technique. Insertion of biliary stent could then be performed over the guidewire through the duodenoscope. The bile leak resolved after keeping the biliary stents in situ for 12 months.