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CC BY 4.0 · Endoscopy 2025; 57(S 01): E1186-E1187
DOI: 10.1055/a-2715-5094
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Gel immersion transpapillary stone removal for recurrent choledocholithiasis

Authors

  • Yota Hirayama

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Tesshin Ban 

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Kei Ando

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Naoto Imura

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Yoshimasa Kubota

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Shun Sasoh

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)

  • Takashi Joh

    1   Department of Gastroenterology and Hepatology, Gamagori City Hospital, Gamagori, Aichi, Japan (Ringgold ID: RIN36884)
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Endoscopic retrograde cholangiopancreatography (ERCP)-guided stone removal using a balloon catheter is a promising approach for patients with small choledocholithiasis (diameter: ≤10 mm [1] [2]). The recurrence of choledocholithiasis significantly increases in patients with certain characteristics, such as dilated common bile duct (CBD), advanced age, history of cholecystectomy, and multiple stones [3]. However, data on endoscopic strategies for the frequent recurrence of choledocholithiasis, debris, or sludge formation are scarce. Gel immersion endoscopy has emerged as a novel technique and has also been reported in ERCP-related procedures [4] [5]. Here, we report the potential of gel immersion ERCP-guided clearance for recurrent choledocholithiasis.

A 94-year-old woman with a history of ERCP-guided stone removals presented with acute cholangitis due to a suspected third recurrence of choledocholithiasis. ERCP-guided stone removal was attempted using a balloon catheter (Extractor Pro; Boston Scientific, Marlborough, USA); however, only the mucous content was removed ([Fig. 1] a, b, [Video 1]). Next, we inserted an endoscopic introducer (EndoSheather; Piolax Medical Device, Yokohama, Japan) into the CBD, followed by bile aspiration and injection of the 10 mL gel (Viscoclear; Otsuka Pharmaceutical Factory, Naruto, Japan) with contrast medium. This maneuver facilitated the removal of small residual stones and debris without adverse events ([Fig. 2] a, b, [Video 1]).

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Fig. 1 Conventional endoscopic retrograde cholangiopancreatography (ERCP)-guided stone removal using a balloon catheter. a Cholangiography is performed during biliary sweep using an inflated balloon. b In an endoscopic view, the sweep with a balloon catheter following the injection of a contrast medium results in the extraction of only mucinous contents.
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Fig. 2 Gel immersion endoscopic retrograde cholangiopancreatography (ERCP)-guided stone removal using a balloon catheter. a Cholangiography using a gel with contrast medium. bIn an endoscopic view, a significant amount of the gel–stone/debris complex is removed.
Gel immersion transpapillary stone removal for recurrent choledocholithiasis.Video 1

The small choledocholithiasis and debris likely escaped through the gap beside the inflated balloon or adhered to the CBD wall during clearance using the balloon catheter ([Fig. 3], [Video 1]). This indicates the incomplete removal of small stones and debris during conventional ERCP-guided stone extraction. In gel immersion ERCP-guided clearance, small residuals are encased in a highly viscous gel, which may facilitate the extraction of the gel–stone/debris complex while preventing its escape alongside retrieval balloon.

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Fig. 3 Schema of gel immersion endoscopic retrograde cholangiopancreatography (ERCP)-guided stone removal using a balloon catheter versus a conventional method. In the conventional method, the debris escapes around the balloon (red arrows). In contrast, the debris is removed and enclosed in a highly viscous gel. Left, conventional; right, gel immersion; pink circles, balloons; brown circles, small stones; brown dots, debris; blue areas, gels.

However, further investigation is necessary to address the outcomes, including pancreatitis and recurrence.

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Publication History

Article published online:
29 October 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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