Endoscopic Management of Benign Pancreaticobiliary Disorders

Abstract

Endoscopic management of benign pancreaticobiliary disorders encompasses a range of procedures designed to address complications in gallstone disease, choledocholithiasis, and pancreatic disorders. Acute cholecystitis is typically treated with cholecystectomy or percutaneous drainage (PT-GBD), but for high-risk or future surgical candidates, alternative decompression methods, such as endoscopic transpapillary gallbladder drainage (ETP-GBD), and endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD), are effective. PT-GBD is associated with significant discomfort as well as variable adverse event rates. EUS-GBD leverages lumen-apposing metal stents (LAMS) for direct access to the gallbladder, providing the ability to treat an inflamed GB internally. Choledocholithiasis is primarily managed with ERCP, utilizing techniques to include balloon extraction, mechanical lithotripsy, or advanced methods such as electrohydraulic or laser lithotripsy in cases of complex stones. Altered anatomy from bariatric procedures like Roux-en-Y gastric bypass may necessitate specialized approaches, including balloon-assisted ERCP or EUS-directed transgastric ERCP (EDGE). Post-operative complications, including bile leaks and strictures, are managed endoscopically using sphincterotomy and stenting. Post-liver transplant anastomotic and non-anastomotic strictures often require repeated stent placements or advanced techniques like magnetic compression anastomosis in refractory cases. In chronic pancreatitis (CP), endoscopic approaches aim to relieve pain and address structural complications like pancreatic duct (PD) strictures and calculi. ERCP with sphincterotomy and stenting, along with extracorporeal shock wave lithotripsy (ESWL), achieves effective ductal clearance for PD stones. When traditional approaches are insufficient, direct visualization with peroral pancreatoscopy-assisted lithotripsy is utilized. EUS-guided interventions, such as cystgastrostomy, pancreaticogastrostomy, and celiac plexus blockade, offer alternative therapeutic options for pain management and drainage of peripancreatic fluid collections. EUS plays a diagnostic and therapeutic role in CP, with procedures tailored for high-risk patients or those with complex anatomy. As techniques evolve, endoscopic management provides minimally invasive alternatives for patients with complex benign pancreaticobiliary conditions, offering high clinical success and fewer complications.

Keywords: bile; calculi; cholangitis; cholecystitis; endoscopy; gallstones; leak; management; necrosis; pancreatitis; stents; strictures; transplant.

Figure 1

(A): CT scan demonstrating gallbladder wall thickening with pericholecystic fluid. The patient was on anticoagulation at the time of presentation (Top). Arrow shows thickened gallbladder wall with pericholecystic fluid. (B): ERCP with the placement of transpapillary double pigtail stent for acute cholecystitis (Left). Arrows demonstrated the pigtail of the stent within the gallbladder lumen. (C): Endoscopic view of transpapillary gallbladder stent placement (Right).

Figure 2

(A): Deployment of distal flange (yellow arrow of the lumen-apposing metal stent into the gallbladder lumen). (B): View of the lumen-apposing metal stent from the duodenum. (C): Balloon dilation of the lumen-apposing metal stent to allow drainage of bile.

Figure 3

Suggested algorithm for endoscopic management of acute cholecystitis.

Figure 4

(A): A large, impacted stone leading to multiple failed attempts with extraction balloon, mechanical lithotripsy; stone was fragmented using a laser lithotripter (yellow arrow) and could be removed with extraction balloon after fragmentation. (B): Shows the effect of laser lithotriptor on the stone. A plastic double pigtail stent is placed in the bile duct to prevent cholangitis from impaction of stone fragments.

Figure 5

(A): Patient with RYGB gastric bypass, presents with choledocholithiasis, undergoes EDGE procedure to enable ERCP through the excluded stomach. GG—gastrogastrostomy, GJ—gastrojejunostomy. LAMS—lumen-apposing metal stent. (B): Shows the passage of duodenoscope through the LAMS into the descending duodenum to perform ERCP.

Figure 6

Suggested algorithm for endoscopic management of choledocholithiasis in Roux-en-Y gastric bypass patients.

Figure 7

(A): High-grade bile leak noted at the common hepatic duct, treated with multiple plastic stents draining different segments, diverting bile from the site of leak. (B): High-grade bile leak treated with multiple double pigtail plastic stents (C): Endoscopic view of the transpapillary plastic stents.

Figure 8

(A): Peripancreatic fluid collection treated with LAMS cystogastrostomy as well as ERCP with transpapillary PD stent. Disrupted duct in the tail of the pancreas leading into the pseudocyst cavity. (Green arrow—post cholecystectomy abdominal drain, blue arrow—extravasation of contrast from the tail of PD into the cyst cavity, yellow arrow—Cystgastrostomy using LAMS). (B): A tail leak and multiple side branches leaking on pancreatogram concerning disrupted duct (Blue arrows—indicate leakage from multiple side branches).

Figure 9

(A): Extracorporeal shock wave lithotripsy, 5000 shock waves performed targeting the stone. (B): Fragmentation of the radiopaque stone. (C): ERCP with stone retrieval. Arrow—fragmented stones.