Peroral Cholecystoscopy-Directed Electrohydraulic Lithotripsy of Symptomatic Cholecystolithiasis in Poor Surgical Candidates

Abstract

Purpose: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones, but not for those who are poor surgical candidates. Choledoscopy-directed electrohydraulic lithotripsy (EHL) using a “baby scope” passed through a side-viewing duodenoscope is effective for treating choledocholithiasis. However, this technique has not been reported for the treatment of symptomatic cholecystolithiasis in patients unable to undergo surgery. This report describes two cases that demonstrate, for the first time, the feasibility of peroral cholecystoscopy-directed EHL (PC-EHL) for treating symptomatic cholecystolithiasis in non-surgical candidates. Case 1: 78 yo female with severe COPD and cholecystostomy tube for recurrent cholecystitis presented with symptomatic cholelithiasis. A laparoscopic cholecystectomy was attempted and aborted due to severe gallbladder inflammation. The patient was a poor surgical candidate based on poor pulmonary status and prior failed surgery. She underwent a PC-EHL of a 3 cm gallstone and multiple smaller gallstones. Subsequently, a 10-Fr, 10 cm cystic duct stent and a 7-Fr CBD stent were placed. After 12 weeks, a repeat ERC showed only fragments of the stones which were washed and removed. A 7-Fr double pigtail gallbladder stent was placed. With follow-up, she has experienced an uneventful recovery and a marked improvement in her symptoms. Case 2: 65 yo male with ischemic cardiomyopathy (NYHA class IV) and recurrent cholangitis s/p cholecystostomy and gallbladder stenting presented with symptomatic cholelithiasis. The patient was a poor surgical candidate based on poor cardiac status. He underwent PC-EHL of a 5 cm gallbladder stone. Subsequently, a 10-Fr double pigtail stent was placed into the gallbladder. After 2 weeks, a repeat ERC demonstrated a 2 cm fragment of the prior stone. A 10-Fr, 10 cm and a 7-Fr, 10 cm double pigtail stents were placed into the gallbladder. The patient is scheduled for cholangioscopy with repeat EHL. With follow-up, he has experienced an uneventful recovery and a marked improvement in his symptoms. Conclusion: These cases represent the first successful demonstration of PC-EHL in the management of symptomatic cholecystolithiasis. This novel technique offers an endoscopic approach to managing patients with symptomatic cholecystolithiasis who are not surgical candidates.