Laser Lithotripsy with an Ultra-slim Upper Endoscope Through a Choledochoduodenal Fistula

Abstract

FigureHere we present an interesting case of 56 yrs of old gentleman s/p cholecystectomy in the past that presented with abdominal pain, jaundice, and weight loss. CT abdomen showed multiple small liver lesions, intrahepatic biliary dilation, and air in biliary tree. He was suspected to have metastatic disease process. However, he was noted to have a choledochoduodenal fistula with a yellowish stone at the opening during ERCP. The opening was wide enough to allow an ultra-slim upper endoscope. It revealed the intra- as well as extrahepatic biliary tree to be full of large stones. We used laser lithotripsy by using a 273 microns holmium laser through the endoscope. Both right as well as left intrahepatic duct stones were progressively broken down into smaller pieces under direct visualization. After duct clearance, no underlying biliary mass was noted. Plastic biliary stents were placed across the fistula. The patient was brought back 2 weeks later for laser lithotripsy of the extrahepatic duct stones via the fistula. Biliary sphincterotomy was performed, followed by duct clearance. Two transpapillary plastic biliary stents were placed. On repeat ERCP 6 weeks later, the duct was clear. The choledochoduodenal fistula was noted to have healed completely. This challenging case has few teaching points: 1) we used the anatomical advantage of naturally created choledochoduodenal fistula to successfully perform laser lithotripsy in both right and left intrahepatic ducts. 2) Direct visualization provided by the ultraslim gastroscope. 3) We used laser rather than electrohydraulic lithotripsy which did not require aqueous media. The water dissipated quickly in our case through the fistula. 4) The importance of duct clearance and maintenance of transpapillary drainage provided by stents that ultimately allowed closure of the fistula.