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]).
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.
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.
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.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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