Alright, I'd like to thank the course directors and the ASG for giving me this opportunity to speak on a fun topic. In 10 minutes, we're going to manage stones of all sizes. These are my disclosures. So CBD stones come in all shapes, sizes and forms. Life is easy when they are one to two. If this mouse would allow me, yes. And then life gets a little difficult when the little ones are multiple in number. And then life is very difficult when there are multiple large stones stacked on top of one another. So endoscopic management of CBD stones has revolutionized in the last two decades. Surgery is now rarely required to manage them. 85 to 90% of the cases can be managed with just sphincrotomy or large balloon dilation or with a balloon sweep and stenting. However, 10% of the stones, they do resist the conventional fragmentation and need multimodality therapy or cholangioscopy and a combination of all of the above to tackle them. There are various guidelines in place for management of CBD stones. And we will jump right into our first case. So 70 year old male presents with abdominal pain, no weight loss, has a prior history of cholecystectomy, slight rise in transaminases and bilirubin. MRCP raised the concern for a dilated CBD with a questionable distilled CBD stone. So we brought the patient in for an EUS plus or minus ERCP to have the further evaluation and a tiebreaker. So here you can see on the EUS, stones were seen in the CBD and then the patient, we proceeded with the ERCP portion. So on ERCP, two filling defects were seen in the CBD. Good biliary sphincrotomy is very necessary within the constraints of the intraduodenal portion that would allow for removal of the stones using traditional balloon sweeps. Whenever you're using the balloon, you want to make sure you size it to the size of the duct and always clean up the distal part of the CBD before you tackle the stones above. I like to push the scope inwards a little and a little the rightward torque to get the downward vector to pull that stone out of the duct. So once we removed the distilled CBD stone, then the balloon was inflated about the more proximal stone, which was then again, smoothly pulled out. Balloon sweeps, again, you want to do some subsequent sweeps to make sure that there is no residual stones in the bile duct. And also the balloon catheter helps to perform an occlusion cholangiogram at the end of the procedure to confirm that there are no residual filling defects and you have a satisfactory cleanup of the bile duct and there is no need to stand. So these are the easy stones that follow conventional methods for management. However, when the stones are multiple large, you need a combination of either making the bile duct opening bigger and making the stone smaller. So we open up the bottom of the bile duct with either a conventional sphincterotomy or a sphincterotomy in combination with a large papillary balloon dilation, and then try to make the stone size smaller, either with a mechanical lithotripsy or with cholangioscopy with electrohydraulic lithotripsy and laser lithotripsy. So here you can see the stone could not be removed with a basket. The attempt was made to remove the stone with the basket and that didn't work. So papillary large balloon dilation is performed. You can see a waste in the center of the balloon and you want to see that waste obliterated. For the large papillary balloon dilation, you want to size it to the distal portion of the duct and do not use the balloon larger than the larger stone. Make sure there is no distal CVD stricture. And once the dilation is performed using a balloon sweep, a large stone is removed from the duct here. Papillary large balloon dilation without a sphincterotomy has a very high risk of post-ERCP pancreatitis. So you always want to make a small cut and then use the balloon dilation. A systematic review of over 16 studies showed that when comparing just sphincterotomy or sphincterotomy with large papillary balloon dilation, there was higher stone clearance rate and lesser need for mechanical lithotripsy for stones that were greater than 10 millimeters than sphincterotomy with large papillary balloon dilation was performed. Using a basket and trying to make the stone smaller, you always want to make sure you have a good size sphincterotomy and a good opening to be able to sweep that stone out. Sometimes I just open the basket and try to sweep the stone out. You want to capture the stone within the basket. Use a basket that is bigger than the size of the stone so you can capture it adequately. And then just like a sweep, you are able to sweep the stone out. But performing mechanical lithotripsy, you want to open this basket always below the stone and then try to capture the stone. Contrast injection can be performed to kind of float the stone into the basket. And then you can jiggle it and try to capture it. And once it's captured, you could then crush the stone and pull the stone fragments out. You want to be very careful that the stone, the basket can sometimes, and that is the biggest challenge, sometimes get caught with the stone and you get an impacted basket. So you want to make sure your endo unit has the endotriptor to save the day because impacted or broken baskets are one of the biggest concerns when using the mechanical lithotripsy. And also mechanical lithotripsy has limited success when it comes to large stones or presence of strictures. Our second case is a 52-year-old male with a prior history of cholecystectomy. He came in with abdominal pain, had some myotransaminases. And ultrasound showed CBD stones. Of course, the patient was brought for ERCP. The patient denied any prior ERCPs, but voila, when we went in, there was a 15-year-old CBD stent at the ampulla. If you think this was difficult, life in endoscopy is always tough, and I'm sure all my colleagues will agree. So there were stones stacked on top of each other in the bile duct, and there were large periampullary diverticula. So of course, we proceeded with cholangioscopy with electrohydraulic lithotripsy. The stone fragments were really crushed down because, again, we didn't have the option of having a large sphincterotomy given the anatomy. Here, you want to make sure that the tip of the probe is close enough to the stone, and you leave a little space to fragment it. And then using balloon sweeps, the duct is sweeped out. I also used the basket to bring out some larger fragments. And you can see on the right-hand side, finally, got complete duct clearance with multimodality therapy. Laser lithotripsy can also be used for large stones. However, there is a cost associated with it and training and the handling of the laser. Studies have compared electrohydraulic lithotripsy and laser lithotripsy. Laser was found to be faster. However, they are both very good effective modalities for fragmenting the stones and breaking down large baldock stones. I always give these patients one dose of antibiotics. We have published data on bacteremia with cholangioscopy, so I personally prefer to give them a dose of antibiotics. Our institution has been part of a multicenter study led by Dr. Kashab, and cholangioscopy was effective in getting big duct clearance in over 97% of the cases in cases of difficult stones. And it was found to be safe and effective in over 95% of the cases. Coming to, can we get the priors? Yeah, various facets of cholangioscopy in the same patient. Here you can see patient had large stones and using cholangioscopy, the stone was fragmented and all the fragments are removed. And a fully covered metal stent was placed to facilitate passage of the fragments. However, the stent, of course, migrated proximally at the next ERCP. And using cholangioscopy, we were able to grab the distal end of the stent and pull the stent out. And the cholangioscope was then reintroduced to make sure that there were no stone fragments remaining. And of course, there were a few fragments remaining and then further balloon sweeps were performed and the duct clearance was achieved. So same patient, multiple rolls of cholangioscopy that helped the patient. When you're doing these cases, make sure you're prepared for nightmares. So just a little video, if there is torrential bleeding or perforation, make sure you're prepared to save the day and keep your patients safe. So in summary, ERCP is safe and effective for managing bile duct stones. There are various modalities available and you may use a combination of sphincrotomy, mechanical lithotripsy, large papillary balloon dilation, or all of the above to clear that stone and surgery is now rarely required. It's a significant advantage in this day and age of health care reform and always keep your patients safe. Thank you.

CBD stones

endoscopic methods

cholangioscopy

lithotripsy

ERCP