Laser Lithotripsy with Direct Cholangioscopy for Complex Biliary Stones

Abstract

Introduction: Biliary stones can be successfully removed in greater than 90% of patients during ERCP with balloon/basket catheters, with some requiring mechanical lithotripsy. Complicated stones that are unable to be managed with standard therapies often require more advanced modalities including extracoporeal shockwave lithotripsy (ESWL), electrohydraulic lithotripsy (EHL) and laser lithotripsy. We report our experience with endoscopic laser lithotripsy with direct cholangioscopy in patients with complex bile stones. Methods: Between March 2001 and November 2008, laser lithotripsy was used for the treatment of complicated biliary stones in 16 patients, reviewed retrospectively. For all procedures, a Holmium Laser was used under direct visualization using cholangioscopy with the SpyGlass System (Boston Scientific, Natick, USA) (15 cases) and, prior to 2006, a mother-daughter cholangioscope CHF B20 (Olympus, USA) (6 cases). Results: Sixteen patients (mean age 63 years, 25% men) with complex choledocholithiasis were treated with laser lithotripsy after failed stone clearance with ERCP using standard therapies including balloon/basket extraction and mechanical lithotripsy (mean 2.6 ERCP attempts). The mean stone size was 22.5mm and mean number of stones was 2.3. All procedures resulted in partial or complete stone fragmentation. Eight of the 16 patients (50%) had complete stone clearance after completion of laser lithotripsy. Eight patients without complete stone clearance received CBD stents and underwent subsequent ERCP with stone extraction using balloon/basket catheters and/or mechanical lithotripsy. All 16 patients eventually had complete resolution of stones. A total of 30 procedures (mean 1.9 ± 0.7 procedures) were performed, including 21 laser lithotripsy sessions (mean 1.4 ± 0.8). Two complications occurred: one patient had nausea and abdominal pain requiring admission post-procedure and one had a wire perforation in the cystic duct during an attempt at mechanical lithotripsy after laser lithotripsy. Conclusion: Resolution of complex biliary stones using laser lithotripsy can obtain in all cases, with few side effects but require a mean of 2.6 sessions. Laser lithotripsy with direct cholangioscopic visualization is safe and effective for treatment of complex biliary stones. Table 1Treatment Outcomes Complete Stone Clearance After Laser Session(s) 8/16 (50%) Persons Requiring Additional Therapy ∗ Additional therapy included CBD stenting with subsequent ERCP with balloon/basket retrieval and/or mechanical lithotripsy. 8/16 (50%) Final Stone Clearance 16/16 (100%) Procedure Complications Nausea/Pain Wire perforation 2 1 1 ∗ Additional therapy included CBD stenting with subsequent ERCP with balloon/basket retrieval and/or mechanical lithotripsy. Open table in a new tab