Therapeutic role of direct peroral cholangioscopy using an ultra-slim upper endoscope

Introduction

Peroral cholangioscopy provides direct visualization of the bile duct and facilitates diagnostic procedures and therapeutic intervention. The currently available mother?Cbaby scope system is not widely used because of its disadvantages. Direct peroral cholangioscopy (POC) with a regular, ultra-slim, upper endoscope can provide a valuable and economic solution for evaluating bile duct lesions, although its therapeutic role in biliary tract disease is uncertain. We assessed the usefulness of direct POC with an ultra-slim endoscope for therapeutic application in patients with biliary diseases.

Methods

Several new techniques and accessories allow therapeutic intervention under direct POC using an ultra-slim upper endoscope with a larger, 2-mm working channel. Intracorporeal laser or electrohydraulic lithotripsy under direct POC is a main therapeutic intervention for patients with bile duct stones resistant to conventional endoscopic procedures. Tumor ablation therapy such as photodynamic therapy and argon plasma coagulation may be performed under direct POC. Direct POC can be applied to guide biliary interventions such as guidewire placement, stone removal, and migrated stent retrieval, using diverse accessories.

Conclusion

Direct POC with an ultra-slim upper endoscope allows therapeutic intervention for patients with biliary diseases. Enhancements of the endoscope and specialized accessories are expected to expand the therapeutic role of direct POC.     

DIRECT PERORAL CHOLANGIOSCOPY AND PANCREATOSCOPY FOR DIAGNOSIS OF A PANCREATOBILIARY FISTULA CAUSED BY AN INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS: A CASE REPORT

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra‐slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69‐year‐old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra‐slim videoendoscope (GIF‐N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra‐slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.     

Current status of peroral cholangioscopy in biliary tract diseases

Peroral cholangioscopy(POC) is an important tool for the management of a selected group of biliary diseases. Because of its direct visualization, POC allows targeted diagnostic and therapeutic procedures. POC can be performed using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope or via the insertion of a small-diameter endoscope directly into the bile duct. POC was first described in the 1970 s, but the use of earlier generation devices was substantially limited by the cumbersome equipment setup and high repair costs. For nearly ten years, several technical improvements, including the single-operator system, high-quality images, the development of dedicated accessories and the increased size of the working channel, have led to increased diagnostic accuracy, thus assisting in the differentiation of benign and malignant intraductal lesions, targeting biopsies and the precise delineation of intraductal tumor spread before surgery. Furthermore, lithotripsy of difficult bile duct stones, ablative therapies for biliary malignancies and direct biliary drainage can be performed under POC control. Recent developments of new types of conventional POCs allow feasible, safe and effective procedures at reasonable costs. In the current review, we provide an updated overview of POC, focusing our attention on the main current clinical applications and on areas for future research.     

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM:To detect and manage residual common bile duct(CBD)stones using ultraslim endoscopic peroral cholangioscopy(POC)after a negative balloon-occluded cholangiography.METHODS:From March 2011 to December 2011,a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography(ERC)and direct POC were prospectively enrolled in this study.Those patients who were younger than 20 years of age,pregnant,critically ill,or unable to provide informed consent for direct POC,as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded.Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.RESULTS:The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct(IHD)in 8 patients(36.4%),to the extrahepatic bile duct where the hilum could be visualized in 10 patients(45.5%),and to the distal CBD where the hilum could not be visualized in 4 patients(18.2%).The procedure time of the diagnostic POC was 8.2 ± 2.9 min(range,5-18 min).Residual CBD stones were found in 5(22.7%)of the patients.There was one residual stone each in 3 of the patients,three in 1 patient,and more than five in 1 patient.The diameter of the residual stones ranged from 2-5 mm.In 2 of the patients,the residual stones were successfully extracted using either a retrieval balloon catheter(n = 1)or a basket catheter(n = 1)under direct endoscopic control.In the remaining 3 patients,the residual stones were removed using an irrigation and suction method under direct endoscopic visualization.There were no serious procedure-related complications,such as bleeding,pancreatitis,biliary tract infection,or perforation,in this study.CONCLUSION:Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.     

Endoscopic direct cholangioscopy by using an ultra-slim upper endoscope: a feasibility study

BACKGROUND: The search for an easier and less cumbersome technique to perform direct visual examination of the biliary tree is still underway. OBJECTIVE: To assess the feasibility of performing endoscopic direct cholangioscopy utilizing an ultra-slim upper endoscope designed for pediatric patients. DESIGN: Prospective, observational, pilot study. SETTING: Tertiary referral center. PATIENTS: Three patients who underwent endoscopic retrograde cholangiography for evaluation and treatment of choledocholithiasis. METHODS: Following the completion of the endoscopic retrograde cholangiography, a 0.035-inch diameter super-stiff Jagwire (Boston Scientific Corp, Natick, Mass) was placed in the common bile duct. Using the wire to maintain access, we removed the duodenoscope and backloaded the wire onto an ultra-slim upper endoscope (GIF-XP 160, Olympus America Inc, Melville, NY), which was advanced over the guidewire under fluoroscopic and endoscopic control into the duodenum and then across the ampulla of Vater into the common bile duct and upstream. RESULTS: Endoscopic direct cholangioscopy was attempted and successfully completed in all 3 patients. One patient was found to have persistent large amount of sludge and stones, and was referred for surgery. In the other two patients, endoscopic direct cholangioscopy demonstrated complete duct clearance, obviating the need for stent placement and repeat endoscopic retrograde cholangiography procedures. LIMITATIONS: Small sample size, pilot study. CONCLUSIONS: Endoscopic direct cholangioscopy with an ultra-slim upper endoscope originally designed for pediatric use is feasible. Future advances in endoscope development, as well as specifically designed accessories, could lead to the next generation of intraductal diagnosis and therapy.     

Early bile duct cancer detected by direct peroral cholangioscopy with narrow-band imaging after bile duct stone removal

Cholangioscopy not only enables the direct visualization of the biliary tree, but also allows for forceps biopsy to diagnosis early cholangiocarcinoma. Recently, some reports have suggested the clinical usefulness of direct peroral cholangioscopy (POC) using an ultra-slim endoscope with a standard endoscopic unit by a single operator. Enhanced endoscopy, such as narrow band imaging (NBI), can be helpful for detecting early neoplasia in the gastrointestinal tract and is easily applicable during direct POC. A 63-year-old woman with acute cholangitis had persistent bile duct dilation on the left hepatic duct after common bile duct stone removal and clinical improvement. We performed direct POC with NBI using an ultra-slim upper endoscope to examine the strictured segment. NBI examination showed an irregular surface and polypoid structure with tumor vessels. Target biopsy under direct endoscopic visualization was performed, and adenocarcinoma was documented. The patient underwent an extended left hepatectomy, and the resected specimen showed early bile duct cancer confined to the ductal mucosa.     

Direct cholangioscopy combined with double-balloon enteroscope-assisted endoscopic retrograde cholangiopancreatography

Double-balloon enteroscope (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) is an effective endoscopic approach for pancreatobiliary disorders in patients with altered gastrointestinal anatomy. Endoscopic interventions via DBE in these postoperative settings remain difficult because of the lack of an elevator and the use of extra-long ERCP accessories. Here, we report the usefulness of direct cholangioscopy with an ultra-slim gastroscope during DBE-assisted ERCP. Three patients with choledocholithiasis in postoperative settings (two patients after Billroth II gastrojejunostomy and one patient after Roux-en-Y gastrojejunostomy) were treated. DBE was used to gain access to the papilla under carbon dioxide insufflation, and endoscopic sphincterotomy was performed with a conventional sphincterotome. For direct cholangioscopy, the enteroscope was exchanged for an ultra-slim gastroscope through an incision in the overtube, which was inserted directly into the bile duct. Direct cholangioscopy was used to extract retained bile duct stones in two cases and to confirm the complete clearance of stones in one case. Bile duct stones were eliminated with a 5-Fr basket catheter under direct visual control. No adverse events were noted in any of the three cases. Direct cholangioscopy with an ultra-slim gastroscope facilitates subsequent treatment within the bile duct. This procedure represents another potential option during DBE-assisted ERCP.     

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

BACKGROUND: Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F "baby" endoscope to administer electrohydraulic lithotripsy. METHODS: Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization. RESULTS: Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months' duration following their final procedure. CONCLUSION: Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.     

Comparison of intraductal ultrasonography with percutaneous transhepatic cholangioscopy for the identification of residual bile duct stones during lithotripsy

BACKGROUND: An imaging modality that can be used to identity small stones after a biliary lithotripsy is required. Intraductal ultrasonography was evaluated by using percutaneous transhepatic cholangioscopy as the gold standard. METHODS: Lithotripsy, under percutaneous transhepatic cholangioscopy guidance, was performed in 20 patients. A thin-caliber ultrasonic probe (2.0 mm in diameter and 20 MHz frequency) was inserted into the bile duct through the percutaneous tract after lithotripsy, and residual stones were identified. This was followed by percutaneous transhepatic cholangioscopy. RESULTS: In the extrahepatic bile ducts, intraductal ultrasonography provided images of all the stones demonstrated on cholangioscopy (n = 11). The sensitivity was superior to that of cholangiography (P < 0.005). However, in the intrahepatic bile ducts, intraductal ultrasonography only visualized the stones located in the cannulated lobe. Extrahepatic stones smaller than 5.0 mm in diameter or in a common hepatic duct larger than 15.0 mm in diameter were missed by cholangiography, but were visualized by the use of intraductal ultrasonography (P < 0.05). CONCLUSIONS: Intraductal ultrasonography is equivalent to cholangioscopy in the extrahepatic bile ducts. Cholangiography and intraductal ultrasonography should be used in combination to image intrahepatic and extrahepatic stones.     

ERCP AFTER ROUX‐EN‐Y RECONSTRUCTION CAN BE CARRIED OUT USING AN OBLIQUE‐VIEWING ENDOSCOPE WITH AN OVERTUBE

Background: We report that an oblique‐viewing endoscope facilitates endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II reconstruction. With this endoscope, we carried out ERCP in Roux‐en‐Y reconstruction. Methods: Fifteen patients with Roux‐en‐Y reconstruction were enrolled. Eleven of these patients had undergone gastrectomy, while Whipple's operation or choledochectomy had each been carried out in two patients. Among the 11 post‐gastrectomy patients, eight had bile duct stones, and there was one case each of pancreatic abscess with chronic pancreatitis, bile duct obstruction due to gallbladder, or pancreatic cancer. The remaining four patients suffered from stenotic anastomosis of choledochojejunostomy. All procedures were carried out with an oblique‐viewing endoscope. Results: The papilla of Vater or anastomosis was reached in 10 patients. In these 10 patients, all planned procedures were completed. Endoscopic papillary balloon dilatation (EPBD) was carried out in three patients with bile duct stones. The remaining three patients with bile duct stones underwent sphincterotomy with tube stent placement, EPBD after sphincterotomy with biliary tube stent placement, and biliary tube stent placement, respectively. Pancreatic stent placement via the minor papilla was carried out in one patient with pancreatic abscess, and a biliary tube stent was introduced in the patient with gallbladder cancer. Two patients underwent cutting of a stenotic anastomosis with a needle knife, followed by balloon dilatation. None of the patients experienced any complications. Conclusion: The results appear to support the feasibility of using an oblique‐viewing endoscope for ERCP in Roux‐en‐Y reconstruction. Further studies including a large population of patients should be planned to confirm these results.     

Clinical utility of intraductal US for evaluation of choledocholithiasis

BACKGROUND: Intraductal US can improve the diagnostic accuracy of cholangiography performed under C-arm fluoroscopy in patients with suspected choledocholithiasis. This study aimed to determine the clinical utility of intraductal US for patient management. METHODS: Patients with suspected choledocholithiasis undergoing ERCP with a C-arm fluoroscope at two tertiary academic medical centers were enrolled. After initial cholangiography, findings and decisions concerning the need for further interventions were recorded. Intraductal US (20 MHz) was then selectively performed in patients with equivocal cholangiography or those without cholangiographic evidence of bile duct stones. Intraductal US was also performed after endoscopic sphincterotomy and stone extraction to confirm bile duct clearance. RESULTS: Fifty-two patients (28 men, 24 women) were enrolled and intraductal US was selectively performed in 35 (64%). Of the 21 patients with normal cholangiography, 8 (38%) had stones or sludge by intraductal US. Endoscopic sphincterotomy was performed as a direct result of intraductal US in these 8 and the findings were confirmed in 7. In the 14 patients in whom cholangiography demonstrated small (<5 mm) or round filling defects, intraductal US concurred in 9 and found air bubble/no stone in 5. Sphincterotomy was avoided in these 5 patients. Overall, intraductal US led to a change in clinical management in 13 of 35 patients (37%) in whom it was performed. CONCLUSIONS: Selective use of intraductal US affects the clinical management of a large proportion of patients who undergo C-arm fluoroscopy-guided ERCP for suspected bile duct stones.     

经口直接胆道进镜对ERCP残留结石的诊疗价值

目的探讨经口直接胆道进镜方法及其对ERCP残留结石的诊疗价值。方法用3-0丝线将0．533mm（0．021in）斑马导丝软头连结于取石球囊前部的导管外面上,成为引导超细胃镜进镜的球囊．导丝“引导装置”,ERCP取石后的十二指肠镜将“引导装置”的取石球囊（连同导丝并行）送至肝内胆管充气锚定,退出十二指肠镜,沿导丝经口插入超细胃镜直至胆道,观察ERCP取石后结石残留情况,如发现残留结石可直接用超细胃镜网篮取出,结石较大则液电击碎再取出。结果46例患者中42例超细胃镜成功进镜至肝门区胆管,4例失败,自口插镜到达肝门区胆管平均时间为11．3min。成功进镜的42例中发现直径i〉4mm结石6例,残留率为14．3％,最大结石直径为10mm×12mm;27例ERCP单纯取石者发现结石2例,15例ERCP网篮碎石后再取石者发现结石4例。6例残留结石中5例直接用取石网篮取出,1例液电击碎后再网篮取出。术后未见严重并发症。结论应用本方法进行经口直接胆道镜诊疗是可行的,能及时诊断ERCP残留结石并予取除,避免再次取石治疗。     

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation

BACKGROUND: Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. METHODS: Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. RESULTS: Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. CONCLUSIONS: Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.     

Single operator peroral cholangioscopic guided therapy of bile duct stones

Since the introduction of endoscopic sphincterotomy, stone clearance of the bile duct can be achieved by conventional endoscopic means in up to 90% of patients with stone disease. Several endoscopic therapies for difficult bile duct stones have been introduced. Laser therapy for stone fragmentation under direct visual control via the peroral insertion of a cholangioscope (POCS) in the bile duct has proven to be highly effective, further raising the success rate of endoscopic biliary stone clearance. However, conventional POCS has not gained wide acceptance because of several technical limitations such as fragility, impaired steerability and the need for two endoscopists. These limitations may be overcome with a newly developed single operator peroral cholangioscope, the SpyGlass(?) Direct Visualization System. First clinical data of SpyGlass guided intraductal stone fragmentation with EHL or laser fibers report high safety and efficacy of the procedure.     

Endoscopic lithotripsy with peroral direct cholangioscopy using a conventional endoscope

Recently,peroral direct cholangioscopy(PDCS) using an ultra-slim endoscope has come into the spotlight.However,the working channel is too small to use various devices for lithotripsy.We report a case of endoscopic lithotripsy with PDCS using a conventional endoscope as a cholangioscope.Computed tomography scan on an 80-year-old female who was admitted with acute cholangitis showed two large stones in the bile duct.Endoscopic retrograde cholangiopancreatography was attempted first.However,mechanical lithotripsy failed because the stone was too large for the basket catheter.Finally,electric hydraulic lithotripsy with PDCS using a conventional endoscope was performed allowed the stones to be cleared completely.In conclusion,PDCS using a conventional endoscope can be an alternative solution for endoscopic lithotripsy for patients with large stones in the dilated bile duct.     

Clinical utility of intraductal US to decrease early recurrence rate of common bile duct stones after endoscopic papillotomy

Background and Aim: The aim of the present study was to determine whether additional intraductal ultrasound (IDUS) to confirm complete stone clearance decreases the recurrence rate of common bile duct stones for a 3‐year period after endoscopic papillotomy (EPT). Methods: IDUS was carried out with a thin‐caliber ultrasonic probe (diameter 2.0 mm, frequency 20 MHz) via transpapillary route after stone extraction. If IDUS showed evidence of residual stones and/or sludge, endoscopic management was performed until IDUS examination was negative. A prospective study was conducted on 59 consecutive patients undergoing additional IDUS after stone extraction between January 1996 and May 2003 (IDUS group). The recurrence rate of common bile duct stones was compared with a historical control group (August 1988 to December 1995) consisting of cases that did not undergo IDUS (non‐IDUS group). Potential risk factors for recurrence of common bile duct stones were assessed by univariate and multivariate analysis on logistic regression. Results: In 14 of 59 patients (23.7%), IDUS detected small residual stones not seen on cholangiography. The recurrence rate was 13.2% (17 of 129 patients) in the non‐IDUS group and 3.4% (two of 59 patients) in the IDUS group (P < 0.05). Multivariate analysis subsequently identified non‐IDUS status as an independent risk factor for recurrence (odds ratio 5.12, 95% CI 1.11–23.52, P = 0.036). Conclusions: Additional IDUS to confirm complete stone clearance after EPT decreases the early recurrence rate of common bile duct stones.     

Endoscopy in the management of choledocholithiasis

Choledocholithiasis (bile duct stones) occurs in 10% to 15% of patients with cholelithiasis. Endoscopic retrograde cholangiopancreatography and biliary sphincterotomy, combined with the use of a variety of available accessories (eg, mechanical lithotriptors), are highly effective in managing most common bile duct stones. The combination of biliary sphincterotomy and papillary balloon dilation allows removal of many stones without the need for mechanical lithotripsy. Large stones may require additional expertise and the use of cholangioscopy with intraductal lithotripsy. Some patients, especially those with intrahepatic stones, require the help of an interventional radiologist or a biliary surgeon. The availability of endoscopists, radiologists, and surgeons interested in and experienced with biliary diseases will allow successful and safe therapy to be tailored to the individual patient.     

Duodenoscopic sphincterotomy in the treatment of the “sump syndrome”

The sump syndrome is recognized as a complication of a choledochoenterostomy (choledochoduodenostomy or choledochojejunostomy) performed for recurrent stone disease. A sump (a pit or well) develops in the distal, nonfunctioning limb of the common bile duct where lithogenic bile, gastrointestinal contents, and debris accumulate. This results in obstruction of the enterostomy stoma producing either cholangitis, pancreatitis pain, and/or cholestasis. It is thought that dysfunction of the sphincter mechanism contributes to the development of this syndrome. Filling defects in the bile duct are appreciated on gastrointestinal series when barium refluxes into the biliary tree through the patent stoma. Threatment has largely been surgical, but, more recently, the availability of ERCP has enabled the endoscopist to make a major contribution to the management of this syndrome. A nonsurgical alternative to treatment is duodenoscopic sphincterotomy which has been performed in 11 patients presenting with the sump syndrome. There have been no recurrences of stones in 1o patients while stones were found in one patient with an open sphincterotomy. In follow-ups of 3–30 months, there was satisfactory relief of symptoms in all patients. Because of these results, duodenoscopic sphincterotomy is recommended as a primary treatment modality in the sump syndrome.Presented in part at poster session, American Society For Gastrointestinal Endoscopy, Digestive Disease Week, 1980.     

Pulsed dye laser lithotripsy of bile duct stones.

Efficacy and safety of pulsed dye laser lithotripsy was tested in 25 consecutive patients in whom bile duct stones could not be extracted after endoscopic sphincterotomy. The patients had one to six (mean, 1.8) bile duct stones (diameter, 10-35 mm; mean, 18 mm) located in the common bile duct (18 cases), the intrahepatic bile ducts (6 cases), or in a long cystic duct stump (1 case). Different approaches were tested depending on the presence of a T tube and on the localization of the bile duct stones. When a T tube was present (7 cases), the lithotripsy was performed under direct vision using a choledochoscope inserted through the T-tube tract. In 18 patients without a T tube in place, the lithotripsy was performed under fluoroscopy using a retrograde approach in case of common bile duct stones (14 cases) or under choledochoscopy using a percutaneous transhepatic approach in case of intrahepatic bile duct stones (4 cases). Fragmentation of all the bile duct stones and a complete bile duct clearance were obtained in all 11 cases with procedures performed under direct vision as compared with only 5 of 14 cases with procedures under fluoroscopic control. Moreover, 6 of the 9 failures using the latter approach were offered another session using a choledochoscope inserted through a percutaneous transhepatic tract and were also successfully treated. No complication related to the laser beam was noted. It is concluded that pulsed dye laser lithotripsy of bile duct stones (that are unable to be removed by standard endoscopic techniques) is safe and efficacious provided that it is performed under direct vision. Technical refinements are needed before this procedure can be reliably performed under fluoroscopy.     

Common bile duct pressure and Oddi sphincter pressure in patients with common bile duct stones with and without juxta-ampullar diverticula of the duodenum.

Resting common bile duct pressure and Oddi sphincter pressure were measured in 16 patients with common bile duct stones, 8 having in addition a juxta-ampullar diverticulum. Pressure measurements were performed with an infused catheter introduced through an endoscope under direct vision. No significant differences in fasting common bile duct pressures were observed between the two groups. The Oddi sphincter had a phasic activity, and the peak pressure was similar in both groups.