By Douglas G. Adler
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Additional info for Advanced Pancreaticobiliary Endoscopy
5 min, although the ideal amount of time required is unknown) . After dilation, the balloon should be deﬂated until it is completely ﬂat and withdrawn from the endoscope (Fig. 7b). The guidewire should be left in place to facilitate access in case of any adverse event occurs. Additionally, ﬂuoroscopy should be used to ensure that there is no free air in the abdomen. Adverse events such as perforation can occur if the stone is incarcerated in between the bile duct wall and dilation balloon .
The use of a gastroscope or a colonoscope to map out the “lay of the land” prior to duodenoscope insertion is helpful in identifying any unexpected anatomic variations as delineating the afferent from the efferent limb. Once the afferent limb is identiﬁed, it can be marked in several ways. A guidewire can be left in place; India ink tattooing or endoclip placement at the site of the anastomosis can all help in easy identiﬁcation of the afferent limb prior to duodenoscopy [93, 94]. Once the major papilla has been reached and when using a duodenoscope, biliary cannulation should be attempted 2 Endoscopic Management of Large and Difficult Common Bile duct Stones 29 toward the 5 o’clock position (reverse angle approach) .
The energy from the shock waves is transmitted to and through the adjacent stones, resulting in their fragmentation (Fig. 6) [5, 11]. During the procedure, continuous saline irrigation of the bile duct is necessary to assure visualization and removal of the stone fragments. Saline also provides a medium for shock wave energy transmission . If the bipolar probe is deployed near the duct wall or away from stone, the hydraulic shock waves could cause inadvertent injury or perforation of the bile duct [5, 11].