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Competing Interests: The authors declare that they have no conflict of interest.

Competing Interests: M. Perez-Miranda is a consultant and speaker for Boston Scientific, Olympus, Medtronic and M.I.Tech. R. Law is a consultant for Boston Scientific, Olympus, Conmed and Medtronic and has received research support from Olympus and Boston Scientific and royalties from Up to Date.

Competing Interests: None

Background: Endoscopic papillary large-balloon dilation (EPLBD) allows for the complete removal of large common bile duct (CBD) stones without fragmentation; however, a significant proportion of very large stones and stones floating above a tapering CBD require lithotripsy. Mechanical lithotripsy and cholangioscopy-guided laser lithotripsy are both effective for stone fragmentation. This study aimed to directly compare, for the first time, the efficacy of these two techniques in terms of stone clearance rate, procedure duration, patient radiation exposure, and safety., Methods: 32 patients with very large CBD stones or with stones floating above a tapering CBD, and in whom extraction after standard sphincterotomy and/or EPLBD had failed, were randomly assigned to mechanical lithotripsy or cholangioscopy-guided laser lithotripsy at two tertiary referral centers. Crossover was allowed as a rescue treatment if the assigned technique failed., Results: Patients' demographic data were not different between the two groups. Mechanical lithotripsy had a significantly lower stone clearance rate in the first session compared with laser lithotripsy (63% vs. 100%; P  < 0.01). Laser lithotripsy rescued 60% of patients with failed mechanical lithotripsy by achieving complete stone clearance within the same session. Radiation exposure of patients was significantly higher in the mechanical lithotripsy group than in the laser lithotripsy group (40 745 vs. 20 989 mGycm 2 ; P  = 0.04). Adverse events (13% vs. 6%; P  = 0.76) and length of hospital stay (1 vs. 1 day; P  = 0.27) were not different., Conclusions: Although mechanical lithotripsy is the standard of care for a very large CBD stone after failed EPLBD, where available, cholangioscopy-guided laser lithotripsy is considered the better option for the treatment of this entity as it provides a higher success rate and lower radiation exposure., Competing Interests: None, (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: None

Competing Interests: None

Competing Interests: None

Competing Interests: Competing interests: Dr. Baron is a consultant for W. L. Gore, Boston Scientific, Olympus, Cook Endoscopy.

Selective biliary cannulation is an essential prerequisite for therapeutic endoscopic retrograde cholangiopancreatography (ERCP). The cap-fitted forward-viewing endoscope has been used for ERCP in patients with surgically altered anatomy. In this case series, 12 patients with periampullary diverticulum underwent ERCP using the cap-assisted forward-viewing endoscope due to failure of biliary cannulation using the standard technique. Successful ERCP was achieved in all patients with no serious complications., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Immunoglobulin G4 (IgG4)-associated cholangitis (IAC) is difficult to diagnose because on cholangiography the associated biliary tract strictures cannot be differentiated from cholangiocarcinoma or primary sclerosing cholangitis (PSC). Serum IgG4 levels show a low sensitivity and specificity and are unreliable, particularly in patients with related diseases such as PSC. As IAC takes place at the biliary epithelium, we hypothesized that IgG4 measurement in bile may have higher sensitivity compared with serum., Methods: Bile and serum samples were collected during cholangiography in 67 patients, including 23 patients with PSC, 25 with cholangiocarcinoma, 14 with choledocholithiasis, and five with IAC. IgG4 was measured in both bile and serum., Results: Bile IgG4 levels were markedly elevated in patients with IAC compared with patients with other biliary disorders. Whereas elevated serum IgG4 levels were found both in patients with PSC and IAC, biliary IgG4 levels were only increased in patients with IAC., Conclusions: The study demonstrates that bile IgG4 measurement is possible and may help to distinguish IAC from other diseases., (© Georg Thieme Verlag KG Stuttgart · New York.)

Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique., (© Georg Thieme Verlag KG Stuttgart · New York.)

There are limited data on the outcome of emergency endoscopic retrograde cholangiopancreatography (ERCP) performed in the intensive care unit (ICU). We sought to assess the frequency, indications, and clinical outcomes of ERCPs performed in ICU patients who were too unstable to be transported to the endoscopy unit. An electronic endoscopy database was used to identify the patients (n = 22) and to assess procedural success, complications, and mortality. The indications for ERCP included suspected biliary sepsis, suspected gallstone pancreatitis, and known choledocholithiasis with cholangitis. Biliary cannulation, which was attempted in all patients, was successful in 19 patients (86 %), and of these 18 (95 %) underwent a technically successful endoscopic therapy. There were no apparent endoscopic complications. Therefore, emergency bedside ERCP in ICU patients, which is primarily performed for the management of suspected biliary sepsis and gallstone pancreatitis, can achieve high technical success rates when performed by experienced endoscopists, although the 30-day mortality rate remains high due to multiorgan dysfunction., (© Georg Thieme Verlag KG Stuttgart · New York.)