Sa1361 CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY IN THE TREATMENT OF DIFFICULT BILE DUCT STONES- A SINGLE CENTER EXPERIENCE

Abstract

Using standard techniques, the treatment of bile duct stones is highly effective in 85-90% of cases. In 5-15% the stones are classified as “difficult” due to their size, location, form, calcification or altered anatomy. For these situations alternative treatment options are needed. Cholangioscopy- guided laser- or electrohydraulic lithotripsy increases the success rate of the bile duct stones treatment up to 100%. To evaluate the efficacy, safety and cost- effectiveness of the cholangioscopy guided laser lithotripsy for the treatment of difficult bile duct stones in the context of complications, price and mean procedure time. Data was collected retrospectively from January 2016 to September 2017. All the patients had previous single-session ERCP, sphincterotomy with or without large balloon dilation and plastic stenting performed and bile duct stones were characterized as “difficult” after attempts for extraction using standard techniques or after detection of anatomical abnormalities of the biliary system /strictures/. Patients were scheduled for cholangioscopy with the SpyGlass DS system (Boston Scientific, Marlborough, MA, USA). A 200 μm single use laser fiber (Cook Medical, Bloomington, IN, USA) was positioned close to the stone and lithotripsy was performed until complete fragmentation has been achieved (Settings- 1,2 mJ, 8Hz). The procedure was followed by balloon- or basket extraction of fragments. CBD clearance was confirmed by cholangioscopy. Further interventions were rescheduled if needed. For the period a total of 16 cholangioscopy- guided holmium laser lithotripsies were performed in 14 patients. 2 complications were documented- hemobilia caused discontinuation of the procedure in a patient with essential thrombocitopaenia and a case of mild cholangitis treated with i.v. antibiotic for 5 days. Nasobiliary drainage was left for 24 hours in 2 patients, 2 patients received temporary plastic stents for cholangitis- profilaxis due to residual debris . No serious adverse events requiring surgery, blood transfusions or ICU admission were noted. Cholangioscopy guided Holmium laser lithotripsy is a safe and effective option to treat difficult bile duct stones. The early implementation avoids multiple ERCP- sessions, surgery and related complications in patients, unsuitable for standard endoscopic treatment. Carefull patient selection is needed in relation with the cost- effectiveness and procedure duration.Table 1ResultsNumber of patients14Impacted CBD stones6/14 (42,8%)CBD stones8/14 (57%)Stones in the common hepatic duct2/14 (14,2%)Intrahepatic stones3/14 (21,4%)Stones in the cystic duct1/14 (7,1%)Size of the stones10-35 mmNumber of sessions until complete clearance1,14Duration of the procedure90-180 min.Complications2/14 (14,2%) Open table in a new tab