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  • 1. Aims and Scope

    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

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    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
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Current Trends and Practice Patterns for Difficult Bile Ducts Stones in Korea

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.

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 et al.4 tried to seek the current patterns and preferences in terms of procedure types and techniques among South Korean endoscopists. This study was organized by the Korean Pancreatobiliary Association, the representative academic society for CBD stones in Korea. The study was conducted by a questionnaire survey from Korean Pancreatobiliary Association members and aimed to accumulate real-world data in Korea.

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.

  1. Park JM, Kang CD, Lee JC, Hwang JH, Kim J. Recent 5-year trend of endoscopic retrograde cholangiography in Korea using National Health Insurance Review and Assessment Service open data. Gut Liver 2020;14:833-841.
    Pubmed KoreaMed CrossRef
  2. Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993;25:201-206.
    Pubmed CrossRef
  3. Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019;51:472-491.
    Pubmed CrossRef
  4. Lee YS, Jeon TJ, Paik WH, et al. National survey regarding the management of difficult bile duct stones in South Korea. Gut Liver 2023;17:475-481.
    Pubmed CrossRef
  5. Doshi B, Yasuda I, Ryozawa S, Lee GH. Current endoscopic strategies for managing large bile duct stones. Dig Endosc 2018;30 Suppl 1:59-66.
    Pubmed CrossRef
  6. Katanuma A, Yane K, Osanai M, Maguchi H. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy using balloon-assisted enteroscope. Clin J Gastroenterol 2014;7:283-289.
    Pubmed CrossRef
  7. Katanuma A, Hayashi T, Kin T, et al. Interventional endoscopic ultrasonography in patients with surgically altered anatomy: techniques and literature review. Dig Endosc 2020;32:263-274.
    Pubmed CrossRef

Article

Editorial

Gut and Liver 2023; 17(3): 349-350

Published online May 15, 2023 https://doi.org/10.5009/gnl230155

Copyright © Gut and Liver.

Current Trends and Practice Patterns for Difficult Bile Ducts Stones in Korea

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.

Body

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 et al.4 tried to seek the current patterns and preferences in terms of procedure types and techniques among South Korean endoscopists. This study was organized by the Korean Pancreatobiliary Association, the representative academic society for CBD stones in Korea. The study was conducted by a questionnaire survey from Korean Pancreatobiliary Association members and aimed to accumulate real-world data in Korea.

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.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Park JM, Kang CD, Lee JC, Hwang JH, Kim J. Recent 5-year trend of endoscopic retrograde cholangiography in Korea using National Health Insurance Review and Assessment Service open data. Gut Liver 2020;14:833-841.
    Pubmed KoreaMed CrossRef
  2. Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993;25:201-206.
    Pubmed CrossRef
  3. Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019;51:472-491.
    Pubmed CrossRef
  4. Lee YS, Jeon TJ, Paik WH, et al. National survey regarding the management of difficult bile duct stones in South Korea. Gut Liver 2023;17:475-481.
    Pubmed CrossRef
  5. Doshi B, Yasuda I, Ryozawa S, Lee GH. Current endoscopic strategies for managing large bile duct stones. Dig Endosc 2018;30 Suppl 1:59-66.
    Pubmed CrossRef
  6. Katanuma A, Yane K, Osanai M, Maguchi H. Endoscopic retrograde cholangiopancreatography in patients with surgically altered anatomy using balloon-assisted enteroscope. Clin J Gastroenterol 2014;7:283-289.
    Pubmed CrossRef
  7. Katanuma A, Hayashi T, Kin T, et al. Interventional endoscopic ultrasonography in patients with surgically altered anatomy: techniques and literature review. Dig Endosc 2020;32:263-274.
    Pubmed CrossRef
Gut and Liver

Vol.18 No.3
May, 2024

pISSN 1976-2283
eISSN 2005-1212

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