Clinical Endoscopy

Percutaneous cholecystolithotomy and lithotripsy for managing acute calculous cholecystitis in non-surgical candidates: a systematic review and meta-analysis: Arsalan Nadeem, Ali Husnain, Aleena Ahmed, Haider Ashfaq, Hamza Ashraf, Zain Ali Nadeem, Khawaja Abdul Rehman, Shahroze Ahmad, Muhammad Rafay Shahzad Cheema; Clin Endosc 2025;58(5):684-695. Published online August 27, 2025; DOI: https://doi.org/10.5946/ce.2024.256

Graphical Abstract Abstract PDF Supplementary Material: Background
/Aims: This study aimed to review and update the evidence regarding the efficacy and safety of percutaneous cholecystolithotomy/lithotripsy (PCCL) for managing acute calculous cholecystitis (ACC) in non-surgical candidates.
Methods
A systematic search of PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Embase was conducted. We included studies focusing on the use of PCCL in patients deemed ineligible for surgery owing to ACC and reporting outcomes such as technical success, stone clearance, recurrence, and length of hospital stay. This review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
Meta-analysis of 13 studies showed a technical success rate of 97%, with stone and cholecystitis recurrence in 10% and 1% of cases, respectively. The pooled average length of hospital stay was 2.79 days. Complications included retained stones (3%), duct perforations (6%), catheter displacement (5%), bleeding (4%), and bile leakage (5%). A sensitivity analysis confirmed the robustness of these results.
Conclusions
PCCL demonstrated high efficacy with minimal recurrence and low complication rates in managing ACC in non-surgical candidates. Further randomized controlled trials are necessary to compare its efficacy and safety with standard care approaches, such as cholecystectomy or percutaneous cholecystostomy.

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Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla: Kanglock Lee, Ji Wook Choi, Yunhyeong Lee, Joung-Ho Han, Seon Mee Park; Clin Endosc 2019;52(1):83-86. Published online June 12, 2018; DOI: https://doi.org/10.5946/ce.2018.060

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

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Impact of Periampullary Diverticulum on ERCP Outcomes and Recurrence of Common Bile Duct Stones
Xiaoxi Xie, Yanni Li, Yonghao Chen, Chong Geng, Yaoyu Guo, Xiao Li, Chunhui Wang
Digestive Diseases and Sciences.2026; 71(2): 681. CrossRef
Biliary cannulation techniques: Optimizing success and minimizing risk
Aryan Jain, Mayur Pabba, Aditya Jain, Savita Madhankumar, Sahib Singh, Saurabh Chandan, Muhammad Khalid Hasan, Mustafa A Arain
World Journal of Gastrointestinal Endoscopy.2026;[Epub] CrossRef
Two-devices-in-one-channel method: a challenging cannulation of intradiverticular major papilla
Renato Medas, Eduardo Rodrigues-Pinto, Pedro Pereira, Guilherme Macedo
VideoGIE.2024; 9(3): 141. CrossRef
Periampullary submucosal saline injection to facilitate intradiverticular papillary biliary cannulation
Jad P. AbiMansour, Ryan J. Law
VideoGIE.2024; 9(8): 368. CrossRef
Endoclip-Assisted Cannulation for a Hidden Duodenal Papilla: Three Cases
Il Soon Jung, Ki Bae Kim, Jun Su Lee, Joung-Ho Han, Seon Mee Park
The Korean Journal of Pancreas and Biliary Tract.2024; 29(4): 167. CrossRef
A “One Accessory and One Guidewire-in-One Channel” Technique in a Patient with Billroth II Anastomosis
Kook Hyun Kim, Sung Bum Kim, Tae Nyeun Kim
Clinical Endoscopy.2021; 54(1): 139. CrossRef
Difficult Biliary Cannulation in Endoscopic Retrograde Cholangiopancreatography: An Overview of Advanced Techniques
Brian M. Fung, Teodor C. Pitea, James H. Tabibian
EMJ Hepatology.2021; : 73. CrossRef
Make mission impossible successful: clip-with-line traction facilitates difficult pancreatic duct cannulation in a patient with duodenal duplication
Wei-hui Liu, Zhao-shen Li, Dong Wang
Endoscopy.2020; 52(09): E346. CrossRef

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Successful Removal of a Large Common Bile Duct Stone by Using Direct Peroral Cholangioscopy and Laser Lithotripsy in a Patient with Severe Kyphosis: Song I Lee, Byung Hun Lim, Won Gak Heo, Young Jun Kim, Tae Hyeon Kim; Clin Endosc 2016;49(4):395-398. Published online March 22, 2016; DOI: https://doi.org/10.5946/ce.2015.109

Abstract PDF

A 75-year-old woman with hypertension presented with acute suppurative cholangitis. Chest radiography revealed severe kyphosis. Abdominal computed tomography revealed a large stone impacted in the common bile duct (CBD). The patient underwent emergent endoscopic retrograde cholangiopancreatography, and cholangiography revealed a large stone (7×3 cm) in the CBD that could not be captured using a large basket. We could not use the percutaneous approach for stone fragmentation by using a cholangioscope because of severe degenerative kyphosis. Finally, we performed holmium laser lithotripsy under peroral cholangioscopy by using an ultraslim endoscope, and the large stone in the CBD was successfully fragmented and removed without complications.

Citations

Citations to this article as recorded by

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery
Cosmas Rinaldi Adithya Lesmana, Maria Satya Paramitha, Laurentius Adrianto Lesmana
World Journal of Gastrointestinal Endoscopy.2021; 13(7): 198. CrossRef
Endoscopic Management of Difficult Bile Duct Stones
Murad Aburajab, Kulwinder Dua
Current Gastroenterology Reports.2018;[Epub] CrossRef

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A Case of Small Intestinal Obstruction due to Bezoars Accompanied with Sump Syndrome: Joo Hee Kim, M.D., Kyo-Sang Yoo, M.D., Hyoung-Chul Park M.D.*, Tae Kyung Lim, M.D., Sun You Moon, M.D., Youn Son Chung, M.D., Su Mi Yoon, M.D., Kyoung Oh Kim, M.D., Yong Woo Chung, M.D., Cheol Hee Park, M.D., Taeho Hahn, M.D., Sang Hoon Park, M.D., Jong H; Korean J Gastrointest Endosc 2008;36(4):228-232. Published online April 30, 2008

Abstract PDF: Sump syndrome is one of the late complications of a side to side choledochoduodenostomy, but it is a rare malady. The anastomosis of the bile duct and small bowel results in exclusion of the distal limb of the common bile duct from drainage of bile with the potential formation of a sump. Food material and bile sludge may accumulate in distal segment of common bile duct and so this cause recurrent bile duct stones. Bezoars frequently result from disturbed passage of the gastrointestinal tract, especially after surgery, and it may develop various symptoms by irritating or obstructing the gastrointestinal tract. The bezoar accompanied with sump syndrome after choledochoenterostomy has not yet been reported in the literature. We report here on a case of small intestinal obstruction due to bezoars accompanied with sump syndrome. (Korean J Gastrointest Endosc 2008;36:228-232)

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Usefulness of Endoscopic Ultrasonography for Diagnosing Choledocholithiasis in Patients with Gallbladder Stones: Ja Seol Koo, M.D., Hong Sik Lee, M.D., Sung Woo Jung, M.D., Woo Sik Han, M.D., Jong Sup Lee, M.D., Hyung Joon Yim, M.D., Sang Woo Lee, M.D., Jai Hyun Choi, M.D., Chang Duck Kim, M.D. and Ho Sang Ryu, M.D.; Korean J Gastrointest Endosc 2007;35(4):228-234. Published online October 30, 2007

Abstract PDF: Background
/Aims: CBD stones (CBDS) are generally thought to originate from the gallbladder. Recently, EUS appears to be the best imaging method for making the diagnosis of CBDS. We conducted this study to evaluate the role of EUS for detecting CBDS in patients with gallbladder stones (GBS) and to determine the parameters for predicting CBDS. Methods: From April 2003 to March 2005, 117 GBS patients were enrolled. The patients' clinical and laboratory findings and the radiologic findings of US, EUS, CT and ERCP were reviewed. The sensitivity, specificity, PPV and NPV of EUS for detecting CBDS were evaluated by using ERCP and intraoperative CBD exploration as the gold standard for diagnosing CB. Results: A total 117 patients received EUS and no complications were encountered. After performing ERCP and/or intraoperative exploration, 62 of the patients were examined for determining the presence or absence of CBDS. EUS shows 95% sensitivity and 95% specificity for identifying CBDS. The overall agreement between EUS and ERCP was 94.8%. The patients with CBDS were older than those without CBDS. Fever, jaundice and cholangitis were more prevalent in the patients with CBDS. The results of liver function tests were elevated more frequently in the patients with CBDS (p＜0.05). Conclusions: EUS is an accurate and minimally invasive method for diagnosing CBDS. Evaluating CBD in patients with gallstones is selectively recommended according to clinical and laboratory findings. (Korean J Gastrointest Endosc 2007;35:228-234)

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무증상 담낭 - 위 누공 1예 ( A Case of Asymptomatic Cholecystogastric Fistula ): Korean J Gastrointest Endosc 2000;20(4):322-326. Published online November 30, 1999

Abstract PDF: Biliary enteric fistulas which are caused by gallstone, peptic ulcer and carcinoma are an uncommon disease. Their incidence appears to increase recently with the advent of endoscopy. The usual types of the fistulas are choledochoduodenal, cholecystoduodenal and cholecystocolonic. But, cholecystogastric fistulas are very rare. Their symptoms are usually nonspecific and pneumobilia has been considered as a clue, but the diagnosis is difficult in most cases. At present, endoscopy is very helpful to the diagnosis. The treatment of asymptomatic fistulas is still in dispute. Endoscopic management is being used at times in recent days. We recently experienced a case of cholecystogastric fistula accidentally. During the evaluation for the cause of anemia, we suspected a fistula on endoscopy and confirmed it on endoscopic fistulography and managed it by endoscopic papillotomy and stone extraction. (Korean J Gastrointest Endosc 2000;20:322-326)

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원저 : 담도 췌장 ; 담도계 담석과 십이지장 유두 주위부 게실과의 관계 ( Original Articles : Biliary Tract & Pancreas ; The Relationship between Biliary Calculi and Juxtapapillary Duodenal Diverticuli ): Korean J Gastrointest Endosc 1997;17(4):507-512. Published online November 30, 1996

Abstract PDF: Background
/Amins: Juxtapapillary duodenal diverticuli are often associated with biliary stones. The aim of this study was to investigate the prevalence of juxtapapillary duodenal diverticuli in biliary stones. Methods: Three hundred and thirteen patients underwent endoscopic retrograde cholangiopancreatography were studied prospectively. Results: Seventy-five patients had juxtapapillary duodennl diverticuli(24%). The occurrence of diver- ticuli increased with age and more commomly in female patients. The prevalence of diver- ticulii was higher in patients with commom bile duct stones(35.6% vs 17.6%; P 0.002) and gallbladder stones(33.3% vs 17.6%; P=0,001) than in patients without biliary stones (17.6%). Conclusions: We conclude that biliary stones are associated with juxtapapillary diverticuli. (Korean J Gastrointest Endosc 17: 507-512, 1997)

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역행성담관조영술에 의한 담즙검사의 의의 ( Significance of Microscopic Examination of Bile Directly Collected during Endoscopic Retrograde Cholangiography ): Korean J Gastrointest Endosc 1993;13(3):567-572. Published online November 30, 1992

Abstract PDF: The usefulness of microscopic examination of pure bile directly collected from the biliary tract during endoscopic retrograde cholangiography and without hormonal stimulation was evaluated in 86 patients. Cholesterol monohydrate crystal and/or calcium bilirubinate granule were observed in the bile of 64% of GB stones, 88% of CBD stones and l00% of IHD stones. But only 4% of non stone control group were positive crystals examinations. According to this results, microscopic examinations:of bile samples collected during endoscopic retrograde cholangiography exhibited a sensitivity and a specificity for cholelithiasis recognition of 82.3% and 95.8%, respectively, with a positive and negative predictive value of 98.1% and 67.6%, respectively. We conclude that microscopic bile examinations of bile samples collected during ERC is useful to investigate in patients with suspected cholelithiasis.

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