For the counterpoint, we could not think of a better person than Raj Shah to make it because he's not only one of the pioneers of cholangioscopy, but importantly, over the years, continue committed to the technique and further continue to refine it. Raj Shah from the University of Colorado. These are my financial disclosures. So you know, with this study that was as a randomized trial looking at sphincterotomy alone compared to sphincterotomy and large balloon dilation, and really this is a 10-year-old study but an excellent one that was done by a Hong Kong group. And you know, it actually showed that if you did sphincterotomy alone compared to balloon dilation, you had a pretty good success rate. And we're pretty good at removing bowel duct stones. So the debate really is, you know, not so much about cholangioscopy as it may be just about how to extract these endoscopically rather than referring to surgery, which I think is an antiquated way to address difficult biliary stones. It really shouldn't be happening in 2022, and that's my take-home message, is that currently we should not be sending patients for bowel duct stones to surgery. I could conclude there, but should I continue? But I think what this data shows is that people are becoming less and less trained related to mechanical lithotripsy, and they're instinctively then doing cholangioscopy because our comfort level with utilizing a basket and lithotripsy has diminished over the last decade or so. So people try to reduce their need to doing mechanical lithotripsy. And I think that's a reasonable thing, and I'll try to show you some data on why cholangioscopy could be superior to the technique of mechanical lithotripsy, and really cholangioscopy may be more adjunctive. So when we're talking about possible use of cholangioscopy, we're looking at patients with difficult bowel duct stones. And so it's not all comers. It's not the one-centimeter stone in a 15-millimeter duct. This is an example of a case I did a few weeks ago in which I think a lot of these issues of difficult stones were addressed. There are multiple stones. The largest was greater than one-and-a-half centimeter. There's an impacted stone here between the cystic duct and the bowel duct, so it's kind of a Moritzi's-type syndrome. And a couple of the stones were cuboidal or barrel-shaped, and there was a distal stricture as well. So all those criteria of difficult stones are represented in this case. When you do the clangogram where you see the MRCP that shows this degree of difficulty, then you're not going to try to just use a basket alone in that setting. You're not going to use just balloon dilation alone. That type of case, you go straight to cholangioscopy. In this case, I utilized laser to then effectively clear the duct or at least fragment it sufficiently that allows you to get some of the fragments out, stent, and then bring them back for complete clearance of the stone. So there's several series or papers on the use of cholangioscopy and lithotripsy, and I include some of the papers here. So it would be very, I guess, convincing to say that our success rate's quite high. Everybody should get cholangioscopy for difficult bowel duct stones. There's data that has compared cholangioscopy to some conventional therapies. This is a paper from James Group looking at single-operated cholangioscopy and laser versus conventional therapy. Sixty patients were included. Stones were pretty large and a moderate size. I don't know if that might actually be balloon dilation, not duct. And the stone clearance was significantly higher in the group that received cholangioscopy. The use of mechanical lithotripsy was permissible in each of the group, each of the arms. But when you look at the balloon dilation in that group, you could make an argument that maybe the balloons just weren't large enough to get rid of the stones that were at hand. But in any event, nine patients that had failed clearance had surgery. And I think per protocol, this is the way the protocol was designed. There's no crossover. Of course, in reality, if we're unable to remove a stone with balloon dilation, maybe mechanical lithotripsy, then you're going to utilize cholangioscopy. If you don't have the experience with it or the availability of that scope, then you would refer the patient to a referral center. And I think that would be the preferred route rather than surgery. So how does lithotripsy of cholangioscopy compared to mechanical lithotripsy for stones that fail balloon dilation? And I bring up this study, and I actually don't know if it's been published. This is an abstract from a few years ago at DDW, which with the pandemic, it feels like it was last year. But this was only 7% of patients failed papillary balloon dilation. And so that gives you an idea of how successful balloon dilation can be. So it's all about patient selection and case selection. So in this group, they looked at 32 patients that failed balloon dilation compared to laser lithotripsy to mechanical. As you might imagine, single session clearance is really important. Be able to clear the duct in a single session for the patient especially in resource intensiveness. All patients in the laser lithotripsy had clearance of their stone. And of course, the fluoroscopy use is less than when you're using mechanical lithotripsy. This is a nice study, a randomized trial looking at cholangioscopy versus balloon dilation. 33 patients in each arm. It's a single center study. Mechanical lithotripsy was permitted in each of the groups, as you might imagine, was higher in the balloon dilation group. Number of stones about three, medium-sized stones, and the single session success significantly higher in the cholangioscopy laser lithotripsy group. The only thing I'd like to point out, even though the adverse event rates are comparable between the two groups, it could be a type 2 error because of the small numbers of patients. Because I think that's a, you know, numerically, it's a significantly higher group. But I tell you, this is worrisome, this perforation of the bile duct from laser and leading to peritonitis. You know, I come from the perspective where I think I've perforated every possible digestive organ there is, ductal structure, hypopharynx, like everything to the rectum. And so that happens. But I think the key here with any of these procedures, as you know, many of you are experienced gastroenterologists, is to recognize these complications that may occur. And then if they do occur, how to address them. You know, stenting should prevent the risk of peritonitis with a bile duct perforation. In any event, that just remains a potential risk with intraductal lithotripsy. So something to keep into consideration. So then, sorry, how much time do I have? There's no timer up here. Keep going? Okay, thanks. So this is a meta-analysis of about 19 randomized controlled trials. And what was interesting, they compared these techniques to the sphincterotomy alone. And in this forest plot, what they see is a significant superiority of cholangioscopy compared to these other techniques, advanced techniques, I consider for bile duct stone clearance. And so the evidence is really weighing toward cholangioscopy for these difficult stones. Hopefully I convinced you of that. What's the economic impact of cholangioscopy for treatment of bile duct stones? So in this study, models populated from two Belgian hospitals, data from about 60 patients with difficult stones. And what they found is a decrease in the number of procedures and costs when utilizing cholangioscopy. So you think, well, that's single use and I'm as frugal as it gets for endoscopists. And when you think about the single use device and you throw it away after 20 minutes, it's kind of, it's humbling. But the reality is if you can save that patient a second procedure, a second anesthesia, second all the other devices and accessories you use, then there could be significant cost savings by being done more efficiently, efficaciously with a single session compared to more. So does everyone with difficult bile duct stones require cholangioscopy? I hope, I mean, the answer really is no, that's not the case. But we looked at our data at the University of Colorado, over 200 patients with a difficult bile duct stones, 80% of them at previous ERCPs, primarily at other institutions. And this is the breakdown of what we used to clear the duct 99% of the time. 99% of the time, we cleared the extra-octotic bile duct and the large balloon dilation, about 20%, mechanical lithotripsy, 40%, a combination of cholangioscopy and introductor lithotripsy with these other techniques, 20%. Whatever it takes, you do it, but you try to reduce the number of procedures required to get it done. So the algorithm for bile duct stone extraction, it's always nice to get guidelines that reflect the practice you've had for a couple of decades. And so this is what the ESG has published a few years ago. If a stone is less than the diameter of the distal duct, do a limited sphincterotomy, large balloon dilation. If it's a cuboidal stone or if the stone is greater than the diameter of the distal duct, consider some lithotripsy technique, mechanical or, if available, cholangioscopy assisted lithotripsy. And then if there's failed clearance or anticipated failed clearance, I'd like to emphasize that. If you anticipate failed clearance of a stone, you might consider not even doing the procedure, referring the patient. Or, of course, if they're sick, then put a stent in and refer the patient for a tertiary care center. The one thing I would disagree with my preceding speaker is this idea that stenting alone will clear the duct of stones. Yes, there's a certain percentage of patients who have a stent and then their stones soften up and you remove them. But please don't let that be your end-all strategy of just stent exchange after stent exchange. Put the stent in, be prepared to do some additional advanced technique the next time to clear that duct. That's all I got.

cholangioscopy

bile duct stones

sphincterotomy

large balloon dilation

difficult biliary stones