Next up, we're going to move on to talk about management of difficult and complex biliary stones, bread and butter of what we do. And so I'm thrilled to introduce Dr. Jason Rogart, who's in New Jersey, my home state, Pennington, New Jersey, where he directs interventional endoscopy at Capital Health. So thank you so much, Jason, for coming, and looking forward to hearing what you have to say here. I'm really honored to be back here. It's been a couple of years since I've been here. It's always a pleasure. Thank you to Linda. Thank you to Uzma for inviting me. My talk is about management of difficult bile duct stones. After academics, I started interventional practice at what was then more of a community household and now is a big regional center. And this is probably the number one referral I get from other ERCPs outside, out in the community, is for bile duct stones. The other major referral I get is for high-risk strictures. So this is an issue that's out there that a lot of sort of bread and butter community practice doctors are still challenged with. So hopefully, today, I can give some tips about how to deal with some of these cases more effectively. OK. So this is an outline of what we'll talk about in the next 30 minutes. So what makes a stone difficult? So we have properties of the stone. So generally, the general consensus is a size greater than a centimeter or, I think in Europe, greater than a centimeter and a half. The shape matters. So a wide stone is going to be more challenging than a long tubular stone. A flat stone can be challenging. And then stones, or a number of stones, more than three stones, can be more challenging. You can see a recent case in the middle there. I think there ended up being about 20 stones. Location makes a difference. So intrahepatic stones are more challenging. Stones upstream to a stricture, whether it's a malignant stricture or a benign stricture, can be more challenging to deal with, as are impacted stones. And then, of course, altered anatomy, whether that's a perianpillary diverticulum, like we saw this morning, or post-surgical patients. So how do we approach the challenging stone? So first, I think it's important, if you know it's going to be a stone case or challenging stone, to gather as much information as possible before you even start. So that involves looking at all the imaging. If I know it's going to be a challenging case, sometimes I'll start with an EUS, just to kind of get a lay of the land, see if I'm dealing with multiple big stones, soft stones, hard stones, stones above strictures. So history, obviously, is very important, as is a patient's ERCP history. Is this their first time they've had stones, or have they had 10 ERCPs for stones in the past? That might be a clue that maybe there's a stone nidus intrahepatically that other people are missing. Make sure you have the appropriate devices in stock in your unit, and also make sure that your staff is well-trained in their use, and that includes physicians. So during the ERCP, there's really two main approaches. One is enlarge the ampullary orifice as much as possible, and the second is to decrease the size of the stones when necessary. One tip here also is, if you have multiple stones that, one of the pictures I showed you where there were 20 stones, don't be greedy. Go one or two stones at a time, and start distally closest to the ampulla. Otherwise, you're just going to impact all those stones at the ampulla and make your job a ton times harder. So I talked about trying to gather as much information as possible before even starting the case. So here is a case of Uzma's, actually. Let's see. How do I play the—there's no mouse. Oh, there we go. So on the fluoroscopic image, this looks like it could be a stricture. So Uzma did spyglass, and instead of a stricture, she saw it was a stone. And so this is a case where maybe knowing that ahead of time could have saved you some time, saved you from doing cholangioscopy initially. So just an example of how pre-ERCP imaging can be helpful. So for standard stone extraction, this is your toolbox. Sphincter tomes to do sphincterotomy, extraction balloons, and baskets. And I already told you this. So for me, I think the sphincterotomy, if you don't do a good one initially, the rest of the case becomes very difficult, or your chances of success are a lot less likely. One of the major reasons I see people out in the community fail ERCP for stones is that they did a small sphincterotomy. They did not really maximize their sphincterotomy. So I'll show you what I mean. So know your anatomic landmarks. So I think we heard this morning during Betsy's discussion that you want to be cutting roughly in the 11 o'clock direction. And you want to know your landmarks. So you want to maximize the extent of your cut. You want to know where. So here's the top fold. It may actually be this one. Can't tell from this picture. But your goal really is to cut up until this point. Now, this is a decent sphincterotomy. But there's more room to cut here. And if you have large stones, you really should try to cut all the way up here. The other thing you want to be aware of is cutting just the mucosal fold isn't good enough. So a lot of times I see these small sphincterotomies as second opinions. There's a big mucosal defect, but much of the sphincter is still intact. Remember that the sphincter is a muscle. And there are internal fibers here. And these are fibers that really should be cut as much as possible. And that can be a little tricky because you need to push your tome in a little bit farther. But cutting these fibers really makes a huge difference. So here are some more pictures of what I was talking about. This is what the ampulla looked like on initial views. It's covered by a couple of folds. So it's really hard to tell the landmarks here. This is all the same patient. So here you can see we're starting to cut. There's two folds here. At the time, I'm not sure which one is going to be the final destination. You can see we've cut through that first fold, but it still looks like there's another fold. So you can keep cutting here. And that's what I did. So we cut to that second fold here and then cut some of these fibers here. So here's a video from one of my former fellows doing a sphincterotomy for a stone case. And I told him I would criticize him on this one if he sent it to me, or critique him, I should say. So he's cutting here. His orientation looks good. There's probably a stone sitting up here. You can see there's a diverticulum here, but luckily the ampulla is down here. And why didn't it not play? OK. I'm not sure why it's not playing. There we go. And should be cutting any moment now. So the cut's going to be this direction, and I'm not sure why it's not going, but this is actually where the cut should end, all the way up there. Most times I'll see doctors go to here and stop. And cutting up here will allow you to get out many more stones. So what if a patient has had a prior sphincterotomy? That's a question that always comes up. So I tell people, look at the anatomic landmark. So if there's more room to cut, cut more. If there's no more room to cut, then use a balloon to dilate and break up those internal fibers. And I'll have some slides on that later. All the data suggests that the adverse events from a repeat sphincterotomy are the same as an initial sphincterotomy. But I'll tell you anecdotally, I don't think that's true. I certainly see more bleeding in my own practice on repeat sphincterotomies. So here's a recent patient that came to me for a difficult stone. And there was very, this is me cannulating. This is the extent of the sphincterotomy here. You can see this is really where it should have been to. So we extended the sphincterotomy and started cutting some internal fibers. And so now you can see here, the whole, this is all cut here. There's actually a little slit here going to the top. And it went great and cleared the stones, no problem. The next day she came back and she was bleeding like stink. And we treated it and she did fine. I put a clip on that area. I don't have a picture of it. But it happens. But you do what you got to do. So how about advanced stone extraction? So that was sort of basic techniques. So dilation-assisted stone extraction, for me, and I think many of my colleagues, has been a complete game changer in the last decade. I very rarely use cholangioscopy or EHL these days. I mean, I still use it frequently, but not as much as I used to because of balloon dilation. So there's dilation-assisted stone extraction. There's mechanical lithotripsy with either the large baskets that you may have seen in the hands-on that crush the stones. You can also use a balloon dilator inside the duct to help make room for mechanical lithotripter or crush the stones themselves just with the balloon. And then there's cholangioscopy. And we heard a little bit about that this morning from Jessica's talk, either with EHL or laser lithotripsy. And there's also intraductal baskets now that you can pass through the cholangioscope. So dilation-assisted stone extraction, the first thing you want to do if it's a native papilla is perform a sphincterotomy. It doesn't need to be a huge one if you know you're going to end up dilating. But by performing a sphincterotomy, you decrease significantly the risk of posterior CP pancreatitis. And then you need to choose your balloon size. So the general rule is to choose the size of the balloon that matches the size of the distal duct, not the size of the dilated portion of the duct. Then you would risk, you would have the risk of perforation. So I use contrast in the balloon. I look for the waist of the balloon at the level of the sphincter to disappear on the fluoroscopic images. Of note, there's really no advantage to dilating for more than 60 seconds. Personally, after 30 seconds of the waist of the sphincters disappeared, I stopped dilating. There's no advantage in my mind to continue on. There's multiple studies that have shown this to be a safe and effective method for clearing stones resulting in a lower need for lithochipsy. And this was a systematic review of over 2,500 patients. As far as one note on the size of the balloon used, so I personally, I start at 10 millimeters if the duct can accommodate that, and then I go up from there. I've gone as high as 18 millimeters. I know there's reports going up to 20, but I've never done that. I try not to go above 15 millimeters. It seems that the risk just increases after that. So with that said, the same week I had that repeat sphincterotomy bleed, I needed to dilate a separate patient up to 15, they also bled. So you never know. So here's a couple pictures as an example. So we're in the upper left dilating with a large caliber balloon. You can see the duct is pretty wide open, and the stone that this patient had came out quite easily. Here's another example of a recent patient. The red arrow on the left panel there, that's the sphincter. This is my balloon, and these are the stones stacked up above it, and a duct that's not very dilated. So I used, this was after a failed attempt at sphincterotomy, I used a balloon dilator to get rid of the waste of the sphincter muscle here. And you can see here on the final images after stone clearance, the sphincter is basically gone here. So here's a video of those things. So this is biliary cannulation. This is sphincterotomy along the edge of a diverticulum, I think. So you'll notice how there was a rush of bile. That's generally a good sign that you've done a good synchrotomy. There was balloon dilation there, and then balloon extraction of these stones, multiple stones. So moving on, mechanical lithotripsy. So this is a large metal wire basket used to crush stones. It can be challenging to capture the stones with these large baskets. Remember, most of these are four or six wire baskets, and you need to get the stone in between all those wires and then close the basket without the stone slipping out. A lot easier said than done. One of the techniques that can be helpful is to try to shake the basket around the stone to get the stone centered within all those wires. If it's a four wire basket, you really need to make sure the stone is within all four of those wires. The success rate's pretty high for mechanical lithotripsy, 84% to 98%. The success is lower if the stone is impacted, because generally it's hard to capture with all the wires, or if the stone is greater than 2 centimeters. Beware, there is a terrible complication that can occur with these baskets, where the basket gets stuck or breaks, or it gets impacted. If that's the case, generally what you do is you cut at the handle level, you cut the lithotripser, and you attach a rescue handle here. And depending on which basket you're using dictates which rescue lithotripser you'll use. If you don't know how to use something like this, you really shouldn't be using baskets like that. So here's a video. There we go. You see the basket opening kind of fills the diameter of the duct. You can see it moving back and forth, shaking, to capture the stone, which is where the contrast isn't filling. Once you've captured it, your assistant just crushes it. And then you can see the fragments there. So I mentioned before I also use a balloon inside the duct sometimes to help achieve success. So that can be done for two different reasons. One is you can inflate a dilation balloon inside the duct across the stone to create more room for the lithotripsy basket to pass and capture the stone. The other way in the last couple of years I've started using these balloons is to inflate the balloon against the stone and trap it between the wall of the duct and the balloon to actually crush the stone. And sometimes these stones are soft. And just by inflating a large caliber balloon in the duct, you can actually crush the stone and then go back and remove the fragments with a balloon. This is a lot of anecdotal reports. There was one small study several years ago showing 100% success rate. I've never had a single complication with this technique. You're always choosing a balloon that's smaller than the duct because you're putting it between the duct wall and the stone. So we heard a little bit about cholangioscopy this morning. It's pretty much all single operator cholangioscopy at this point. Again, this allows for direct visualization of the stone so that you're not misdiagnosing it as a stricture. The scope itself has dedicated irrigation and suction ports. And you can pass accessory devices through the cholangioscope. Those include electrohydraulic or laser lithotriptors, small baskets, biopsy forceps. And it's become pretty easy to set up. So on the left, that's a laser lithotriptor. And there's different types of lasers. There's holmium lasers, yag lasers, et cetera. I use the electrohydraulic lithotriptor. I think a lot of people have moved that direction. I find it a little bit easier to use. And it works pretty well. So it's kind of like playing a video game. It's really, if you can do cholangioscopy, you can do EHL. You're infusing the duct with saline. And you're just putting the probe right, sort of not touching, but right up to the stone. And you're sitting on the foot pedal once you've dialed in your appropriate settings. And this is pretty effective. And almost always, this works. It can take a while. So I usually schedule these cases for two hours, personally, if there's more than one stone. So there is a lot of data at this point on EHL and laser lithotripsy. And it shows a very high success rate, around 97%, with a very acceptable adverse event rate. So a couple of my own tips for EHL. Make sure when it's set up that you confirm with your tech or your nurse that they are infusing with saline, not water. Keep in mind that the tip of this fiber is very fragile. So as you pass it down the scope and through the elevator, just be very careful. You also want to make sure at the back end you are not bending the fiber next to the rubber cap where you're putting the devices through. You can literally just crack it. Don't touch the tip to the stone, tip of the catheter to the stone. It'll burn out and fray apart really quickly. And you'll have to move on to your next. If you have large, really large stones or lots of stones, you may go through a few of these fibers in one case to make sure you have plenty on hand. So I mentioned the Calangioscope basket before. It's a 15 millimeter basket, relatively new to the market. It goes right through the accessory channel on the Calangioscope. You can use it to remove small stones, generally less than 10 millimeters in size, more frequently using it to remove stone fragments after EHL. But it can be very helpful for small intrahepatic stones, as well as cystic duct stones. It does have limitations. You don't have much mobility with this particular basket. And it's not a crushing basket. So every time you capture a stone, everything comes out. You're pulling the spy scope and the basket out of the duct. Then you're pulling the scope and everything else out of the patient's mouth, cleaning everything out, putting it back in, and starting over again. So there was some discussion this morning of using Calangioscope to confirm ductal clearance. And I think, I'm not sure if it was this study, but studies have shown that there's actually high rates of residual stones after standard stone extraction when you think you've cleared the duct, up to 24% in this one study that's now a decade old. My own question has always been, I'm not sure if it's ever been answered, are these stones actually clinically significant? I think most times not. But I think there are some times where you have those patients who come back with recurrent bile duct stones. And the reason is that they've never cleared completely their bile ducts. So when should you consider it? When do I consider it? So in a patient with numerous small stones in a large duct, where you may be fooled by your final cholangiogram, I think it can be very helpful. The patient I mentioned who keeps coming back with bile duct stones, where you're like, oh, is this one of those patients who forms de novo stones in their bile ducts? Or is it a patient who's just never been completely cleared? And then after patients come back after EHL or laser lithotripsy, I think it's useful to go in, because there's going to be lots of stone fragments as a result of the prior procedure. So patients with surgically altered anatomy, not really going to talk too much about this. It's kind of beyond the scope of this talk. But it's important to review the anatomy. And it's important to review the anatomy to make sure you have the right tools and the right scopes necessary to be successful, or you choose the right way to go about the case. So for example, a Roux-en-Y gastric bypass patient is much different than a patient who had a Whipple with regards to your approach and with regards to the options, with regards to the scope or devices you need to complete the case. So for example, in the gastric bypass patient, you're not going to get to the ampulla with an ERCP scope or a colonoscope. So you're talking either about a double balloon scope or an edge procedure. Or what I usually tend to do is the laparoscopic-assisted transgastric ERCPs. So what if you fail stone extraction in a single session ERCP? Well, don't worry. It happens. It happens to everyone, even all the faculty in this room. So you have some options. You can stent either a single or multiple plastic stents or a fully covered metal stent. You can bring back another day after leaving the stents in. I prefer to leave stents in for two to three months at a minimum, with the idea that these stents, via a shearing process, can help soften up these stones. I'm honestly not sure if there's good science behind that. But I can tell you, at least experientially, it works. And then if you're out in the community, consider sending these patients to a tertiary center, depending on the tools you have available locally, as well as the expertise. So there are guidelines. Our last guidelines from ASG about stones are a couple of years old now, in 2019. It does touch upon some of the things we talked about so far with regards to difficult-to-pile luck stones. There's also guidelines from Europe, from the same year, that are more or less in alignment. So with that said, I kind of have my own algorithm. That's not completely outlined in these guidelines. And I think this is, to me, a common-sense algorithm that incorporates both guidelines, as well as literature that's out there. So for a normal stone, sphincterotomy, balloon extraction, and if the patient's not going to have surgery at that admission, I usually leave a stent, just based on some of the data of stone recurrence between when there's a delay in cholecystectomy. So if a patient has a difficult stone, I try to do as big of a cut as I can. And if that doesn't work, then a large balloon dilation. And if that's successful, same idea. If the patient's not getting their gallbladder out right away, I leave a stent. And then I bring back after they have their gallbladder out to take the stent out. If this is not successful, then the question I ask is, does this patient have cholangitis or not? If they do not, I'll do cholangioscopy with EHL. And if that's not successful, I'll stent. And then I'll bring back for repeat cholangioscopy and EHL, usually for a little bit longer period of time. If they do have cholangitis, I am not a fan of doing cholangioscopy in somebody who has pus in their duct. So I will attempt mechanical lipotripsy. And if that doesn't work, I'll stent. And I'll bring back as an outpatient for cholangioscopy and EHL. I'm sure everybody has a different algorithm in this room. What? I was just going to say, yeah, there's two things I do. Yes, just like everybody uses different stents, and everybody has different opinions on whether to leave a PD stent at all, a lot of what we do with therapeutics, there isn't just one way. And that's actually, for me, one of the things I love about therapeutics is you can think outside the box, and you can do things your own way. And it may work exactly the same, or you may have exactly the same success as your colleague across the country who does it differently for different reasons. Maybe that's the way they were trained. But there's not just one way to do things. So some additional tips before we finish up. Budget enough time for the case. There's nothing worse than starting a big case and feeling under the gun with regards to time. So for example, if I know I'm going to be doing a complicated EHL case, even though I may not need two hours, I just block out for two hours. And if I finish ahead of time after an hour, great. I can cook at lunch or coffee or whatever. Or my staff is happy because nobody needs to stay late that day. I always budget more than I actually need for everything I do in therapeutics, not just this. I think it's good advice. And again, don't do too much of a patient's cholangitic with frank pus. I think you just really want to stabilize the patient, get them better, decompress them. And then you can worry about being aggressive on another day. Don't forget about post-TRC-P pancreatitis prophylaxis. We heard about that this morning. I use Indosyn on everybody now. I didn't used to use Indosyn on everybody. Many years ago when that study first came out, I was just doing high-risk patients. I've seen no side effects from Indosyn. I've seen no extra bleeding from Indosyn. Nobody's gotten renal failure from Indosyn. The only people I don't give Indosyn to are pregnant women and people who don't have an anus. Those are literally the only two people who don't get Indosyn. Or they have anaphylaxis. I've yet to meet somebody with anaphylaxis to Indosyn. I mentioned earlier, use pre-ERCP imaging to help guide your plan. And that might involve doing an EUS at the same session. Don't forget about antibiotics for cholangioscopy. Personally, I give them routinely regardless of the indication. Remove, and this may be controversial too, any stones greater than a centimeter. I take a Roth net and I take them out through the mouth, especially if there's multiple stones like that. There's the theoretical risk of gallstone ileus, and it's just easy to do. And then this point I can't emphasize enough. Where is this? Take care of the whole patient. I can't tell you how many times I've gotten referred, a 99, 100, 101-year-old lady with ridiculously large stones that have probably been developing for 30 years, and I'm asked for stone clearance because the other doctor was unsuccessful. They may not need to have their stones cleared. If they have multiple comorbidities, they're demented, they just may need permanent decompression and patency in their bile duct. So yeah, I try to give it a go, but if it looks like they're gonna require multiple sessions I usually, even before I start, have a conversation with the family about what are our goals here? How many times are you, what's your tolerance for more procedures? And then lastly, encourage your surgeons to proceed with cholecystectomy soon, usually within 30 days. I try to get them to operate during the same admission, which is a bit of a change from 10 years ago when they were more likely to let patients cool down, go home, and then come back. So in summary, most bile duct stones can be removed via ERCP. Goals for challenging or large stones include enlarging the ampullary opening and reducing stone size. Know your equipment. Everybody in that room should know the equipment. Be creative, think outside the box. Again, there's not just one way to do things. And then know your limits. Everybody, no matter how experienced you are, should know your limits, not just in general, but also that day. If this is your 10th case and it's six o'clock at night, don't struggle for two hours. Just stent and bring the patient back or refer to another institution. That's it, thank you.

difficult stones

stone properties

stone management

sphincterotomy

balloon dilation

cholecystectomy