title: Endoscopic management of radio-opaque bile duct stones.
abstract: BACKGROUND
  Majority of the bile duct stones (BDS) are radiolucent (RL) and are amenable to conventional endoscopic extraction techniques. There is no publication that specifically discusses the optimal management of radio-opaque (RO) BDS and makes a distinction from the strategy followed for RL BDS.
  
  
  METHODS
  Data of patients with BDS managed endoscopically from January 2009 till June 2015 were retrospectively reviewed. Diagnosis of RO stone was established during initial fluoroscopy, just prior to obtaining a cholangiogram. Endoscopic retrograde cholangiopancreatography (ERCP) was done using therapeutic duodenoscope. Stone extraction was attempted initially using conventional techniques. Balloon sphincteroplasty or mechanical lithotripsy (ML) or both were done if conventional techniques failed. Cholangioscopy-guided intracorporeal holmium laser lithotripsy (LL) was done when all the above techniques failed.
  
  
  RESULTS
  Fifteen patients were found to have RO stones in the bile duct during the study period. ERCP was successful in all patients. Discrepancy of the stone size in relation to the lower CBD diameter was seen in eight patients (53.34 %). Stone extraction with conventional techniques was successful in 2/15 patients (13 %). Successful controlled radial expansion (CRE) balloon sphincteroplasty/ML was possible in 5/15 patients (33 %). Cholangioscopy guided LL was done in eight patients (53.34 %) with successful pulverization of RO BDS (100 %).
  
  
  CONCLUSIONS
  RO bile duct stones provide unique challenges for endoscopic management with success of conventional techniques in only about half of them (46 %). RO stones detected on fluoroscopy are extremely hard and difficult to crush with lithotripsy basket probably due to high calcium content. Cholangioscopy guided LL provides an excellent alternative management strategy.
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr. E. Borges Road, Parel East, Opp Shirodkar High School, Mumbai, 400 012, India. drsurya_b@yahoo.com.
authors.forename: Suryaprakash
authors.initials: S
authors.lastname: Bhandari
authors.affiliation: Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr. E. Borges Road, Parel East, Opp Shirodkar High School, Mumbai, 400 012, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Maydeo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001652:Bile Ducts / Q000601:surgery*; D002758:Cholangiography; D002760:Cholangiopancreatography, Endoscopic Retrograde; D002769:Cholelithiasis / Q000175:diagnosis* / Q000601:surgery*; D003952:Diagnostic Imaging; D016145:Endoscopy, Digestive System; D005260:Female; D006801:Humans; D008096:Lithotripsy / Q000379:methods*; D017602:Lithotripsy, Laser; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D025321:Surgery, Computer-Assisted; D016896:Treatment Outcome
keywords: Balloon sphincteroplasty; Bile duct stones; Cholangioscopy; Laser lithotripsy; Mechanical lithotripsy; Radio-opaque; Radiolucent