ERCP Bootcamp for the Endoscopy Team (Live and Virtual) | December 2023-Rogart

Rogart_Difficult bile duct stones

Pdf Summary

In this document, Dr. Jason Rogart provides an overview of the management of difficult bile duct stones. He begins by discussing what makes a stone difficult, including factors such as size, shape, number, and location. He emphasizes the importance of gathering information before the procedure and ensuring that appropriate devices are available and that the staff is well-trained in their use.<br /><br />Dr. Rogart then discusses standard stone extraction techniques, such as sphincterotomy, extraction balloons, and baskets. He advises extracting one stone at a time to prevent them from becoming impacted at the ampulla. He also highlights the importance of sphincterotomy, including the use of the endocut setting and maximizing the extent of the cut.<br /><br />The document also covers advanced techniques for stone extraction, such as dilation-assisted stone extraction (DASE) and mechanical lithotripsy. DASE involves performing biliary sphincterotomy and then using a balloon dilation to decrease the risk of post-ERCP pancreatitis. Mechanical lithotripsy involves using a large metal wire basket to crush the stone.<br /><br />Other advanced techniques discussed include cholangioscopy-assisted extraction, electrohydraulic lithotripsy, laser lithotripsy, and the use of intraductal baskets. Dr. Rogart provides tips and pearls for these techniques, including the careful handling of fragile fibers in electrohydraulic lithotripsy and the use of a cholangioscope basket for the removal of small stones/fragments.<br /><br />The document also touches on the use of cholangioscopy to confirm ductal clearance and discusses the management of patients with surgically altered anatomy. Dr. Rogart advises understanding the anatomy, choosing the appropriate scope, and budgeting enough time for the procedure.<br /><br />Finally, Dr. Rogart provides additional tips for stone extraction, including the use of pre-ERCP imaging, the importance of post-ERCP pancreatitis prophylaxis, and the need for cholecystectomy to mitigate recurrence.<br /><br />Overall, the document provides a comprehensive overview of the management of difficult bile duct stones, including standard and advanced extraction techniques, tips, and pearls for successful stone removal.

Keywords

difficult bile duct stones

stone management

stone extraction techniques

sphincterotomy

extraction balloons

mechanical lithotripsy

DASE

cholangioscopy-assisted extraction

electrohydraulic lithotripsy

post-ERCP pancreatitis prophylaxis