Gut and Liver https://doi.org/10.5009/gnl19157 Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography
Author Information
Yousuke Nakai1,2 , Tatsuya Sato2 , Ryunosuke Hakuta2 , Kazunaga Ishigaki2 , Kei Saito2 , Tomotaka Saito2 , Naminatsu Takahara2 , Tsuyoshi Hamada2 , Suguru Mizuno2 , Hirofumi Kogure2 , Minoru Tada2 , Hiroyuki Isayama3 , and Kazuhiko Koike2
Departments of 1Endoscopy and Endoscopic Surgery and 2Gastroenterology, Graduate School of Medicine, The University of Tokyo, and 3Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan

Yousuke Nakai
Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo 113-8655, Japan
Tel: +81-3-3815-5411, Fax: +81-3-5800-9801, E-mail: ynakai-tky@umin.ac.jp
© The Korean Society of Gastroenterology, the Korean Society of Gastrointestinal Endoscopy, the Korean Society of Neurogastroenterology and Motility, Korean College of Helicobacter and Upper Gastrointestinal Research, Korean Association the Study of Intestinal Diseases, the Korean Association for the Study of the Liver, Korean Pancreatobiliary Association, and Korean Society of Gastrointestinal Cancer. All rights reserved.

Abstract
Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.
Keywords: Cholangioscope; Choleodcholithiasis; Cholangiopancreatography, endoscopic retrograde; Endosonography; Lithotripsy
Abstract
Endoscopic management of bile duct stones is now the standard of care, but challenges remain with difficult bile duct stones. There are some known factors associated with technically difficult bile duct stones, such as large size and surgically altered anatomy. Endoscopic mechanical lithotripsy is now the standard technique used to remove large bile duct stones, but the efficacy of endoscopic papillary large balloon dilatation (EPLBD) and cholangioscopy with intraductal lithotripsy has been increasingly reported. In patients with surgically altered anatomy, biliary access before stone removal can be technically difficult. Endotherapy using two new endoscopes is now utilized in clinical practice: enteroscopy-assisted endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-guided antegrade treatment. These new approaches can be combined with EPLBD and/or cholangioscopy to remove large bile duct stones from patients with surgically altered anatomy. Since various endoscopic procedures are now available, endoscopists should learn the indications, advantages and disadvantages of each technique for better management of bile duct stones.
Keywords: Cholangioscope; Choleodcholithiasis; Cholangiopancreatography, endoscopic retrograde; Endosonography; Lithotripsy
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