Andres Gelrud, MD, gives the presentation - The Difficult Stone
ANDRES GELRUD:So I'm going to be talking about the difficult stone. And the conflict of interest has not changed over the past half an hour. You know, I think that this is a really interesting and fun time to be doing this type of procedures, because there's so many new concepts that we have learned over the past couple of years. So many new, what I call, toys. You know, new equipment that we have been using to solve these problems. And I'm going to go over what I think is the most important, more relevant. And actually, I took a lot of this talk from this presentation in DDW, which was superb for those of you that were present. These are abstracts 363 and 364 that were very complete and very informative. And in a very nice way, particularly from Marty Friedman, summarized everything that you need to know about the difficult stone. I have added also a little bit about pancreatic stones, I think the major part of the stones I spoke about in the previous talk. So let's get started. What about biliary stones? You know, it's extremely important that we review, as [INAUDIBLE] just said, some type of non-invasive procedure that led to the referral, or led to the indication of the ERCP. By the time that we're doing the ERCP, we know that this is going to be therapeutic procedure. We know there are stones, because we saw them on ultrasound. We saw them on MRCP. Or we saw them on EUAs. We need to know, are they large or small? That's going to help determine which type of procedure we're going to do. Single or multiple? I'm going to show some cases. Of both a stricture, if a stricture is present. Particularly in a liver-transplant patient, could this be a cast? Bile-cast syndrome, that we're seeing more and more. Transplants are being done more and more. Altered surgical anatomy, which I hope that I'm going to be able to give you a little bit of guidance, based on the published literature of what we should be doing with this patient population. Particularly the Roux-en-Y that we're seeing so many. And then, we'll jump into pancreatic duct and keep it simple. And we'll talk about small versus medium sized. Large stones we spoke to already. And what are the different tricks that we have now to remove the stones? Distal proximal to a stricture, that is very important to determine the treatment that we offer. And dilated versus normal-size main pancreatic duct, which is a point that Dr. Matthews brought up, and I 100% agree with him. Large duct [INAUDIBLE], diffuse calcification, stones. I also believe that surgery, it's the best treatment option. Something that I should have mentioned also when we were having the discussion is that frequently, for different reasons, these patients are not good surgical candidates. And actually, it's our surgeons are ones that are asking us to please do endotherapy in this patient population. So we work, we refer a lot to each other. And again, the idea of working as a team, it can not be stressed enough. So going back to the difficult stone, treatment options. We have mechanical lithotripsy. This is something that we have been doing, and we're doing more and more. Particularly for the large stones, giant stones, that you know will not go through the major papilla, or through a stricture unless you break it into little pieces. Sphincterotomy and balloon dilation. We have multiple papers coming out for the past four or five years. And when you look at the literature, there were people already seven, eight years ago already publishing about this concept of dilating the papilla to remove stones. But for whatever reason, there was such a lag into us starting to use this as a standard of care in our patient population. Altered surgical anatomy, I'll show in a minute. And when to refer the patients to surgery. There's a subset of patients that have stones in their bile duct. But remember, if they have an altered anatomy, they have stones in the gallbladder, and are a good surgical candidate. If this is a patient that I really want to be spending two hours to try to do a procedure endoscopically that has to go to the OR, my answer is absolutely not. My answer is go straight to the OR, have the cholecystectomy. If you want, we can do a laparoscopic-assisted stone extraction. ERCP, with stone extraction. But if you're going to be removing a gallbladder, you may want to take the stones, or the multiple stones, or the giant stone, in the operating room at the same time. I like to mention also electrohydraulic, or holmium laser lithotripsy. This is something that I remember doing a lot. You know, at least a couple a month. And I can tell you that since I have been here for almost two years, there has only been one case that I have rented the holmium laser lithotripter to do a cholangioscopy with this type of laser therapy. Because with the new technologies and the new equipment, most of the stones we are able to remove without the need of using this type of equipment. This is a patient actually that you see, a relatively one, 1.4 centimeter bile duct. But as you can see in the left, in the fluoroscopic image, the common bile duct, it's packed with small stones. This is a patient that I believe that doing an extended sphincterotomy, a big sphincterotomy, and just with a good balloon, starting distally, and then going proximally as we're clearing the duct, would be enough. And you can see the stones in the right. This a patient that doesn't need a common-bile duct stained. Yes, this patients, personally, if I'm getting the main PD when I'm trying to get into the common-bile duct, I would always leave a soft, main-pancreatic duct. If I don't get into the PD as I'm trying to cannulate the bile duct, I would not attempt to get into the PD to liver stained. But I would definitely give a rectal [INAUDIBLE] medicine for the prevention of post-procedure pancreatitis. Then on the other hand, you have these patients with larger stones, or giant stones, that are almost two centimeters, or bigger than two centimeters, depending who reads it. If it's you, if it's the radiologist, or somebody else. But the interesting part here is that in the image to the left, you see a relatively dilated duct. But still, not as dilated as the proximal. This stone actually was impacted distally. And these patients are very, very tricky. Because if you follow what we're seeing in the literature, that you can dilate with an esophageal dilation balloon this area, I would say up to 15, and I'm sure most of you would agree, that that's 15 millimeters in dilation. The likelihood that you're going to perforate the pancreas, the likelihood that this patient is going to wake up with gripping acute pancreatitis, it's extremely high. And I know that because there are already case reports and series showing that these patients, when they're being dilated, particularly when the distal duct, the intrapancreatitic portion, it's not as dilated as are both the stones. When we're aggressive dilating, we're giving this patient, very likely, a bad episode of pancreatitis. This is the perfect candidate to go in with mechanically lithotripsy. There's different types, different companies. You use the one that you like the most. Very effective treatment on crushing the stone into little pieces so you can remove it either with a lithotripter, or go back in with a balloon, and finish cleaning up the duct. As you can see in that image. What you see here in this occlusion cholangiogram after clearance of the bile-duct stone. And we want to see good drainage. We want to see the duct actually draining a good amount of this contrast spontaneously. And here, by the way, a take-home message. Use half contrast in a concentration for the for the MRCP contract. Why, when you have so much space between one wall of the duct and the other, and you have a small stone? The likelihood that you're going to see it is extremely low. By dilating, by diluting, sorry, the MRCP contrast, you're going to be most likely able to see the small stone particles that may have been left behind. Or even one bigger stone that may be in the intrahepatics when they are dilated. So that's something to keep in mind. And that's a good take-home message. We have [INAUDIBLE] other patient population that have stones, and that you want to dilate the bile duct, because the distal part, it's also very dilated. You can do a small sphincterotomy. Dilate up to 11, 12, 13, 14 15. There's reports, there's people doing up to 17, 18. Extremely aggressive. And you can do it up to the side, up to the dilation of the proximal common-bile duct. Soon after, you can see actually the intrabiliary portion. I can tell you that in a couple of cases, I have seen patients with low cystic duct take off. You can see the opening in front of you. And at the beginning, it's a little bit scary, but these patients do actually very, very well. You can balloon sweep this large stone, obtain an occlusion cholangiogram. And this patient goes home without a stent. Again, unless you cut into the main PD and you wanted to leave a soft stent in there. So this patient doesn't have to come back. Without going into too much detail, for the sake of time, endoscopic balloon dilation. Alone, it's not recommended in the United States. We had a nice conference during DDW, a couple of fast-tracks being presented. In the Caucasian pollution, significantly increases the risk of post-procedure pancreatitis. What we learned from the papers coming from Japan and Asia, is that the duration of the dilation, it's critical. These group published in 2002 a large meta-analysis, that they showed that when you dilate for two or three minutes, these major papillas, again, the idea is not to cut, but only to dilate. The thinking is that you can remove the stones and the sphincter will regain function. Believe it or not, there's a study that was presenting in DDW this year showing manometric studies, showing that truly, the sphincter regains function. Again, the message that I'm trying to give is that in the Asian population, the incidence of post-procedure pancreatitis is extremely low. In the Caucasian population, extremely high. So we, in the US, strongly discourage the use of this technique. I don't know how well this is projecting, but there's a systemic review that was published in 2006 also is going over these concepts. And in the Caucasian population, those are the results that we saw. Altered-surgical anatomy, we just briefly spoke about it. I can tell you that you can do percutaneous cholangiography via previous PTC in a subset of patients. And I'll show which one is the best candidate for this. We rarely do it here in the US. But if the patient already comes with a PTC, that was placed in another institution, and are coming for the expertise that we can provide, that we can help, if there's a tract that is already well-formed and mature, we can go in and easily access the area. We have single, double balloon enteroscopy, very long procedures. I shouldn't be saying this in front of a microphone, very painful procedures. Particularly when you have what I'm about to show. You have the patients with Roux-en-Y gastric bypass. I can tell you that for the past couple of years, most of us will take this patient straight to the operating room and do a laparoscopic-assisted ERCP instead of playing with a single, or double balloon scope to try to do the RCP when we don't have the special equipment that we need. When you have a front-viewing scope without an elevator, just makes a procedure so much longer and more complicated. I'm sorry that the name of Marty Friedman is not coming up here. But I just wanted to show some of the things that are being done with EUS access. He had so many abstracts showing different techniques of EUS access for the gallbladder, with the new access stent, that it's showing to be very, very promising. This is a patient with a Roux-en-Y. I can tell you that the imaged her to the right, it's what you see once you reach the major papilla. Imagine trying to cannulate what we call a virgin papilla, that has never been touched. It's a papilla that is-- the difficulty that it's going to be to get in there. Sometimes we are able to get in there. Sometimes it's a nightmare. You continue to get into the PD. Or you're using dilation techniques and the patients wake up with bad pancreatis. What I started to do for a period of years was to gain access into the stomach. So that way, as you can see here in the left, and you can see the amount of scope inside, just to reach this area. And do a PEG. Wait for the PEG, and I would put a 26 French PEG. Wait for the tract to mature. And I would wait at least a good three weeks. Bring the patient back and I'm here retroflexing the pediatric ERCP scope through the PEG site that I created during the previews. A single or double balloon, whatever you have in your institution to do the procedure without the need of laparoscopic or any major surgical intervention. I want to make this very clear. Nowadays I would only do this if my surgeon is telling me there's no way I'm going to take this patient to the OR. Please do it in your room that is very similar to an operating room. So these are very rare cases that we're still doing. When to refer directly to surgery? It's what we said before. I just wanted to mention this special populations that we rarely see in the US. I'm sure that our hepatology colleagues see it more than what we do for this procedure. The condition that used to be called oriental cholangiohepatitis, now called recurrent pyogenic cholangitis. Most of these patients actually have very localized segmental disease. At least the ones that we see here in the US. And just going for a segmental resection would be the best way to go. The patient will get the best treatment. Good surgical candidate for gallbladder in situ-- multiple stones, giant stones. I would send this patient straight to the operating room. And if the surgeon wants me to do a laparoscopic-assisted ERCP, I'm more than happy to help. What about pancreatic stones, to finish the conversation about stones and what's new. Again, team approach. I cannot stress this enough. We make the decision. Endoscopic therapy, because the stones are small, or relatively small. Because there are usually some proximal or distal to a stricture that we know we can safely dilate and remove the stones. And we know what the size of this main PD is, because we have previous images. This is the whole menu of devices that are available. And I'm sure I have [INAUDIBLE] at least a 20 different pieces of devices, that I know that exist, or that I don't even know that exist that could be used. But this is what we use the most. Be careful. Where are the stones? Parenchymal or parenchymal and ductal as you see in the left. That's a surgical patient with a dilated duct. The patient in the right, very few stones. Localized in the head. We would all agree that we would take this patient for endoscopic therapy to begin. Patients with small stone without strictures, and a patient that has a common bile duct, a main pancreatic duct, that is relatively normally sized. Very easy to cut the major pancreatic duct sphincter. Sweep it, and the stone will come out nicely. We tend to use wires and baskets instead of balloons. These stones are very sharp and they tend to pop the balloons, so we're usually using spiral wires, baskets, and so, whatever you have in your unit will work. There's this other type of patient that we have here that has a distal stricture, as you see here. We tend to dilate the strictures a little bit lower than the sides of the proximal aspect of the main PD to facilitate a stone extraction. You can go up to four, six, or even more, depending how dilated the duct is. This patient has multiple stones that are not too big in size. That you know that by dilating the stricture, as you see here, these stones may come out. As a side comment, any pancreatic-duct stricture, you have to think about cancer until proven otherwise. So as you're doing this, you are also getting cytology brush to rule that out. And you can see how easy these stones are removed. They're small. Basket. We're leaving two stents behind to help remove whatever may be stuck in the parenchyma that may be embedded, to facilitate drainage. And when you go back a couple of weeks later, you can then remove the stent and finish your job. To conclude, we try to do what I call, and many of us call, personalized medicine. Personalized therapy for this patient population. Again, based on size, locations, one or multiple stones, and at the end, your personal preference. Remember, we have to work hand-in-hand with our surgeons. Altered-anatomy. I cannot stress this enough. Roux-en-Y. Personally, and this is our approach in our institution, we do a laparoscopic-assisted ERCP. Rarely we're going to be going with a single or double balloon. Biliary tool. You can go straight within the ERCP. Hepaticojejunostomies with short limbs, I would very gladly go in with a single or double balloon. You're hunting for the Hepaticojenjunostomy that most of the time, it's easy to get in. And we published our series last year in November on distorted anatomies with a Roux-en-Y anastomosis. When in doubt, just place a stent. Think about it, what you want to do. Call your colleague. Make a good plan for your patient. And with this, I'm going to conclude and thank you again for your attention.
