Affiliation:
1. Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, United Kingdom of Great Britain and Northern Ireland
2. Gastroenterology and Hepatology, Columbia University Medical Center, New York, United States
Abstract
Abstract
Background and study aims The characteristics of difficult stones requiring cholangioscopy-assisted lithotripsy are poorly defined. We sought to determine clinician perception of these characteristics and decision-making in biliary endoscopy.
Methods One hundred twenty-four delegates attending an online
course were invited to assess 20 clinical stone cases. Each image was graded on a 4-point
Likert for: grading of stone difficulty, confidence of clearance with conventional endoscopic
retrograde cholangiopancreatography (ERCP) methods, likelihood of needing
cholangioscopy-assisted lithotripsy, and confidence of clearance with one session of
lithotripsy. An independent reviewer rated each case on largest stone size, stone number,
presence of stricture distal to stone, size of stone relative to distal duct size, and acute
common bile duct (CBD) angulation < 135°. Multilevel (mixed) statistical methods with a
two-level model were utilized with multilevel ordinal logistic regression.
Results Stone size and location, stricture and stone
diameter:duct ratio impacted perceived procedural difficulty P <
0.01). Stone:duct ratio (< 50% odds ratio [OR] 0.22, P <
0.001), stricture (OR 7.26, P < 0.001) and stone location
impacted confidence of clearance with conventional ERCP. Intrahepatic and cystic duct stones
were least likely to engender confidence (P < 0.01). The same
factors plus CBD angulation < 135° predicted cholangioscopy requirement (P < 0.01). Stone number did not influence procedure difficulty or
cholangioscopy requirement. Strictures (OR 0.29, P < 0.001) and
location, especially intrahepatic (OR 0.42, P < 0.001) impaired
confidence in clearance with one cholangioscopy session.
Conclusions Ductal anatomy, the presence of a stricture distal to a stone, cystic and intrahepatic stones and stones larger than the distal duct are considered by endoscopists to be significant predictors of requiring cholangioscopy-assisted lithotripsy.
Subject
Obstetrics and Gynecology