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Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.
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Jaihwan Kim 
Correspondence to: Jaihwan Kim
ORCID https://orcid.org/0000-0003-0693-1415
E-mail drjaihwan@snu.ac.kr
See “National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea” by Yoon Suk Lee, et al. on page 475, Vol. 17, No. 3, 2023
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Gut Liver 2023;17(3):349-350. https://doi.org/10.5009/gnl230155
Published online May 15, 2023, Published date May 15, 2023
Copyright © Gut and Liver.
In the case of common bile duct (CBD) stone, endoscopic retrograde cholangiopancreatography (ERCP) is regarded as the standard treatment. In South Korea, the numbers of ERCP have increased, and the CBD stone is the most common indication.1 For most CBD stones, the removal is possible with standard procedures such as endoscopic sphincterotomy or endoscopic papillary balloon dilatation followed by a basket or balloon catheter. However, 10% to 15% of biliary stone extraction is challenging because of the stone characteristics or the patient's anatomy.2 The stones in this situation are referred to as difficult CBD stones, and they usually require additional clearance techniques.
According to the latest European Society of Gastrointestinal Endoscopy (ESGE) guidelines on managing difficult CBD stones, several endoscopic techniques are suggested as follows.3 Endoscopic sphincterotomy and endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopy-assisted lithotripsy, and extracorporeal shock wave lithotripsy. However, there was no universal standard technique, and procedures for this situation were commonly determined by the experience and preference of endoscopists.
Because of the complexity of the procedure and the diverse clinical situation, the management of difficult CBD stones has not been standardized. From this background, Lee
According to this study, 75% of Korean ERCP endoscopists preferred "endoscopic papillary large balloon dilatation after endoscopic sphincterotomy," and the preferred diameters of the large balloon were 13 to 15 mm for 1 minute for large CBD stones. Although the management of the large and difficult stones remains debatable, the current preferred basic techniques among Korean ERCP endoscopists were compatible with the recent ESGE guidelines.
However, there was a different outcome about incomplete clearance of bile duct stones. Compared to mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shock wave lithotripsy, which are regarded as the effective technique and suggested by ESGE guidelines,3,5 Korean ERCP endoscopists preferred temporary biliary stenting and the following ERCP as the rescue therapy. Such a discrepancy may be due to different situations, including medical costs, inadequate reimbursement, and the availability of medical devices such as peroral cholangioscopy. Although the strategy by Korean endoscopists was different from the ESGE guideline, it is worthy of being another option according to the medical cost and availability of the new expensive devices.
ERCP in patients with surgically altered anatomy is always challenging, and various ERCP techniques, including endoscopic ultrasound-guided or balloon enteroscopy-assisted ERCP, are reported as the novel endoscopic technique.6,7 However, cap-fitted forward endoscopy was the most common method for Billroth II anastomosis, and percutaneous transhepatic cholangioscopy was for patients with Roux-en-Y anatomy or the second choice for patients with failed initial procedures. The significant difference in the management of patients with surgically altered anatomy between Korea and other countries also reflects the different medical situations.
In spite of the limitation that this study was performed only by the members of Korean Pancreatobiliary Association who were highly experienced, the outcomes presented the current practice patterns for difficult CBD stones in Korea. As the baseline surveillance reports, the study would be expected to use for the strategy regarding the management of difficult CBD stones. In addition, it can be inferred that the different medical situations strongly influenced the pattern of complex practice. Therefore, our own guidelines that reflect the situation in Korea are anticipated in the future.
No potential conflict of interest relevant to this article was reported.
Gut and Liver 2023; 17(3): 349-350
Published online May 15, 2023 https://doi.org/10.5009/gnl230155
Copyright © Gut and Liver.
Jaihwan Kim
Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
Correspondence to:Jaihwan Kim
ORCID https://orcid.org/0000-0003-0693-1415
E-mail drjaihwan@snu.ac.kr
See “National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea” by Yoon Suk Lee, et al. on page 475, Vol. 17, No. 3, 2023
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
In the case of common bile duct (CBD) stone, endoscopic retrograde cholangiopancreatography (ERCP) is regarded as the standard treatment. In South Korea, the numbers of ERCP have increased, and the CBD stone is the most common indication.1 For most CBD stones, the removal is possible with standard procedures such as endoscopic sphincterotomy or endoscopic papillary balloon dilatation followed by a basket or balloon catheter. However, 10% to 15% of biliary stone extraction is challenging because of the stone characteristics or the patient's anatomy.2 The stones in this situation are referred to as difficult CBD stones, and they usually require additional clearance techniques.
According to the latest European Society of Gastrointestinal Endoscopy (ESGE) guidelines on managing difficult CBD stones, several endoscopic techniques are suggested as follows.3 Endoscopic sphincterotomy and endoscopic papillary large balloon dilatation, mechanical lithotripsy, cholangioscopy-assisted lithotripsy, and extracorporeal shock wave lithotripsy. However, there was no universal standard technique, and procedures for this situation were commonly determined by the experience and preference of endoscopists.
Because of the complexity of the procedure and the diverse clinical situation, the management of difficult CBD stones has not been standardized. From this background, Lee
According to this study, 75% of Korean ERCP endoscopists preferred "endoscopic papillary large balloon dilatation after endoscopic sphincterotomy," and the preferred diameters of the large balloon were 13 to 15 mm for 1 minute for large CBD stones. Although the management of the large and difficult stones remains debatable, the current preferred basic techniques among Korean ERCP endoscopists were compatible with the recent ESGE guidelines.
However, there was a different outcome about incomplete clearance of bile duct stones. Compared to mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shock wave lithotripsy, which are regarded as the effective technique and suggested by ESGE guidelines,3,5 Korean ERCP endoscopists preferred temporary biliary stenting and the following ERCP as the rescue therapy. Such a discrepancy may be due to different situations, including medical costs, inadequate reimbursement, and the availability of medical devices such as peroral cholangioscopy. Although the strategy by Korean endoscopists was different from the ESGE guideline, it is worthy of being another option according to the medical cost and availability of the new expensive devices.
ERCP in patients with surgically altered anatomy is always challenging, and various ERCP techniques, including endoscopic ultrasound-guided or balloon enteroscopy-assisted ERCP, are reported as the novel endoscopic technique.6,7 However, cap-fitted forward endoscopy was the most common method for Billroth II anastomosis, and percutaneous transhepatic cholangioscopy was for patients with Roux-en-Y anatomy or the second choice for patients with failed initial procedures. The significant difference in the management of patients with surgically altered anatomy between Korea and other countries also reflects the different medical situations.
In spite of the limitation that this study was performed only by the members of Korean Pancreatobiliary Association who were highly experienced, the outcomes presented the current practice patterns for difficult CBD stones in Korea. As the baseline surveillance reports, the study would be expected to use for the strategy regarding the management of difficult CBD stones. In addition, it can be inferred that the different medical situations strongly influenced the pattern of complex practice. Therefore, our own guidelines that reflect the situation in Korea are anticipated in the future.
No potential conflict of interest relevant to this article was reported.
pISSN 1976-2283
eISSN 2005-1212
Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE
| Yong Chan Lee |
Professor of Medicine Director, Gastrointestinal Research Laboratory Veterans Affairs Medical Center, Univ. California San Francisco San Francisco, USA |
| Jong Pil Im | Seoul National University College of Medicine, Seoul, Korea |
| Robert S. Bresalier | University of Texas M. D. Anderson Cancer Center, Houston, USA |
| Steven H. Itzkowitz | Mount Sinai Medical Center, NY, USA |
All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
The remaining articles are usually sent to two reviewers. It would be very helpful if you could suggest a selection of reviewers and include their contact details. We may not always use the reviewers you recommend, but suggesting reviewers will make our reviewer database much richer; in the end, everyone will benefit. We reserve the right to return manuscripts in which no reviewers are suggested.
The final responsibility for the decision to accept or reject lies with the editors. In many cases, papers may be rejected despite favorable reviews because of editorial policy or a lack of space. The editor retains the right to determine publication priorities, the style of the paper, and to request, if necessary, that the material submitted be shortened for publication.
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