When Cholangioscopy-Guided Electrohydraulic Lithotripsy May Solve the Problem

Abstract

The majority of common bile duct (CBD) stones can be managed effectively via Endoscopic Retrograde Cholangiopancreatography (ERCP). Cystic duct (CD) stones are less common and, due to their location, are not easily accessible via traditional techniques. In the past this has necessitated surgery, which carried with it sufficient morbidity. Presently these stones may be managed by lithotripsy under direct visualization. ERCP with single operator cholangioscopy guided electrohydraulic lithotripsy (EHL) is one system employed in their management. Recent studies have shown over a 50% success rate in stone extraction after a single procedure and over 75% success rate after a second procedure. This case describes the successful treatment of an obstructed CD utilizing ERCP with cholangioscopy EHL. Our patient is a 27-year-old female with no past medical history who presented with complaints of nausea and severe right upper quadrant pain. Blood work was remarkable for a total bilirubin of 7.5 mg/dL and elevated transaminases (ALP 372 U/L, ALT 678 U/L, AST 533 U/L), Lipase was 171 U/L. Abdominal CT showed cholelithiasis, choledocholithiasis, low insertion of the CD and a dilated CBD of 9mm. She subsequently underwent ERCP with cholangioscopy EHL. Initially ERCP with balloon extraction was done. Multiple stones were removed yet stones were still present in the CBD at the CD takeoff. Cholangioscopy with EHL was then performed. A cholangioscopy scope was used to directly visualize the CBD; multiple stones were noted at the level of the CD. The most distal was removed by EHL. The additional stones were deep into the CD and could not be reached. The procedure concluded with biliary plastic stent placement with clear evidence of bile drainage. The patient tolerated the procedure well and underwent cholecystectomy prior to discharge. CD obstruction presents a challenge to treat via traditional endoscopic methods. Historically surgical intervention was associated with significant morbidity. Laparoscopic surgery is associated with a high risk of conversion to open surgery (41%) in complicated cases (Mirizzi syndrome), complications (16%) and re-operation (5%). Cholangioscopy with EHL however, has been demonstrated to be a safer and effective technique. More so it has been shown to be as, or more, effective than Extracorporeal Shock wave Lithotripsy and the prior two man operated direct visualization EHL system.1358_A.tif Figure 1: CT Abdomen Pelvis w contrast, coronal image. Multiple stones noted within the common bile duct and cystic duct.1358_B.tif Figure 2: Multiple filling defects present in CBD during ERCP.1358_C.tif Figure 3: Cystic duct with calculus impacting opening visualized with cholangioscope.