Electrohydraulic Lithotripsy Research Articles

Electrohydraulic lithotripsy with direct peroral cholangioscopy via double-balloon enteroscopy and endoscopic retrograde cholangiopancreatography in a liver transplant recipient.

Electrohydraulic lithotripsy with direct peroral cholangioscopy via double-balloon enteroscopy and endoscopic retrograde cholangiopancreatography in a liver transplant recipient.

Electrohydraulic lithotripsy for ball valve syndrome due to stent-stone complex after endoscopic ultrasound-guided hepaticogastrostomy.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is the standard endoscopic procedure for malignant biliary obstruction [1] [2]. However, the rate of EUS-HGS-associated adverse events remains high, and various severe complications, including risk factor and rescue techniques, have been reported [3] [4] [5]. We present a rare case of electrohydraulic lithotripsy (EHL) for ball valve syndrome due to a stent-stone complex after EUS-HGS.

Acute Pancreatitis following Percutaneous Electrohydraulic Lithotripsy.

The gold-standard treatment of acute calculous cholecystitis is cholecystectomy. For patients not suitable for surgery, endoscopic or percutaneous techniques can be used for gallbladder decompression. The national percutaneous cholecystostomy rates have increased by 567% from 1994 to 2009*. Some of these patients are still not surgical candidates after the acute cholecystitis episode has resolved. Hence, it is crucial to have a management plan in place for such patients. There are several peroral endoscopic treatment options available, including ultrasound-guided transmural drainage, lithotripsy, and transpapillary stenting**. Furthermore, due to the advent of percutaneous biliary endoscopes, interventional radiology (IR) can now perform percutaneous lithotripsy and gallstone removal followed by cystic duct stenting. This method aims to internalize gallbladder drainage without the need for a long-term external cholecystostomy tube. Acute pancreatitis is a rare complication that can arise following interventions involving the biliary and cystic ducts. Acute pancreatitis can occur after retrograde ampullary manipulation during endoscopic retrograde cholangiopancreatography. However, this can sometimes happen after percutaneous antegrade interventions performed by IR. In this report, we will examine a rare complication that occurred in a patient with acute calculous cholecystitis: acute pancreatitis following percutaneous electrohydraulic lithotripsy with cystic duct stenting performed by IR.

Definitive nonsurgical management of stump cholecystitis with EUS-guided lumen-apposing metal stent placement and electrohydraulic lithotripsy.

Video 1Definitive nonsurgical management of stump cholecystitis with EUS-guided lumen-apposing metal stent placement and electrohydraulic lithotripsy.

Electrohydraulic lithotripsy for a large biliary stone at a hepaticojejunal anastomosis site by refluxing water from a contrast catheter.

Electrohydraulic lithotripsy for a large biliary stone at a hepaticojejunal anastomosis site by refluxing water from a contrast catheter.

Transjejunal ERCP, EUS-guided gallbladder drainage, and cholecystoscopy with direct electrohydraulic lithotripsy with large gallstone removal in Roux-en-Y anatomy.

Video 1Transjejunal ERCP, EUS-guided gallbladder drainage, and cholecystoscopy with direct electrohydraulic lithotripsy with large gallstone removal in Roux-en-Y anatomy.

Efficacy and Safety of Electrohydraulic Lithotripsy Using Peroral Cholangioscopy under Endoscopic Retrograde Cholangiopancreatography Guidance in Older Adults: A Single-Center Retrospective Study.

Background and objectives: The safety of electrohydraulic lithotripsy (EHL) in older adults remains unclear. We aimed to investigate the efficacy and safety of EHL using peroral cholangioscopy (POCS) under endoscopic retrograde cholangiopancreatography (ERCP) guidance in older adults aged ≥80 years. Materials and Methods: This retrospective clinical study was conducted at a single center. Fifty patients with common bile duct stones who underwent EHL using POCS under ERCP guidance at our institution, between April 2017 and September 2022, were enrolled in this study. The eligible patients were divided into an elderly group (n = 21, age ≥80 years) and a non-elderly group (n = 29, age ≤79 years), and were analyzed. Results: A total of 33 and 40 EHL procedures were performed in the elderly and non-elderly groups, respectively. After excluding cases in which stone removal was performed at other institutions, complete removal of common bile duct stones was confirmed in 93.8% and 100% of the elderly and non-elderly groups, respectively (p = 0.20). The mean number of ERCPs required for complete removal of bile duct stones was 2.9 and 4.3 in the elderly and non-elderly groups, respectively (p = 0.17). In the EHL session, the overall occurrence of adverse events was eight and seven in the elderly (24.2%) and non-elderly (17.5%) groups, respectively; however, the difference was insignificant (p = 0.48). Conclusions: EHL using POCS under ERCP guidance is effective in patients aged ≥80 years and there was no significant increase in adverse event rates compared to those aged ≤79 years.

Long-term outcomes of pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones.

Background and study aims Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has proven to be an effective first-line therapy in symptomatic chronic pancreatitis (CP) patients with obstructing pancreatic duct (PD) stones 1 . However, long-term outcomes of endoscopic EHL remain unknown. The aim of the present study was to evaluate the long-term treatment effects of EHL as first-line therapy and to compare with those obtained in a historical cohort of patients who underwent extracorporeal shockwave lithotripsy (ESWL) as primary treatment. Patients and methods An observational retrospective single-center long-term follow-up study was performed including 19 consecutive patients who previously underwent endoscopic EHL compared to 18 patients who underwent ESWL followed by endoscopic retrograde pancreatography (ERP). The primary endpoint was long-term treatment success after EHL or ESWL defined as no recurrence of symptomatic intraductal stones confirmed on imaging. Secondary endpoints for the EHL-population included long-term clinical success (i. e., a similar or lower Izbicki Pain Score or reduction in opiate usage as compared to 6-month follow-up), quality of life (QoL), pancreatic function and hospital re-admission rate. Results In the EHL group, 37 % of the patients developed recurrent symptomatic PD stones versus 61 % in the ESWL group after a median follow-up of 35.0 and 76.5 months. Of the patients with recurrence, 71 % versus 100 % underwent a reintervention. Median time to recurrence was 12.0 versus 13.0 months. Clinical success sustained in 58 % of the EHL patients. QoL was not significantly different compared with 6-month follow-up and baseline. Conclusions Also at long-term follow-up, endoscopic EHL as first-line treatment is moderately effective for symptomatic CP patients with treatment success rates that seems at least equally effective as ESWL.

Electrohydraulic lithotripsy through endoscopic retrograde cholangiopancreatography combined with SpyGlass in the treatment of complex pancreatic duct stones: A case report and literature review.

The incidence of pancreatic duct stones (PDS) is less than 1%. After the formation of stones, the lumen of the pancreatic duct is blocked, and the pancreatic juice cannot be discharged smoothly, resulting in the impairment of the internal and external secretions of the pancreas. Several national guidelines now recommend endoscopic retrograde cholangiopancreatography (ERCP) as the treatment for PDS. The emergence of SpyGlass makes it possible to visualize the ERCP blind area of the pancreatic system directly. Electrohydraulic lithotripsy (EHL) under SpyGlass can crush large and pressure-resistant stones into smaller fragments, significantly improving the success of the endoscopic treatment of large stones. Here, we report a patient presented with acute alcohol-associated pancreatitis, found to have PDS on imaging, who underwent ERCP combined with SpyGlass (EHL), avoiding surgery, reducing trauma, and being discharged from the hospital with a rapid recovery. Therefore, endoscopic therapy is effective and safe for PDS patients. The combination therapy of this patient is the first use of SpyGlass for PDS in our centre, which marks a new stage in the application of endoscopic therapy for pancreatic diseases.

Spy basket retrieval method of an embedded hepaticogastrostomy stent (with videos).

EUS-guided hepaticogastrostomy (EUS-HGS) is performed for benign biliary diseases as an alternative therapy for ERCP. However, a critical adverse event such as stent migration was reported.[1] Recently, stent retrieval method in the HGS route using Spy bite (Boston Scientific, Marlborough, Massachusetts, USA),[2] forceps,[3] or balloon[4] has been reported. We report a case that the plastic stent (PS) retrieval method using Spy basket (Boston Scientific) [Figure 1] and grasping the flap of PS was efficient as a new stent retrieval method.Figure 1: Spy basket (Boston Scientific, Marlborough, Massachusetts, USA)A 70-year-old man with a history of pancreaticoduodenectomy was admitted to our institution to treat intrahepatic biliary stones. Because we failed to remove stones under enteroscope-assisted ERCP due to the instability of the scope, we decided to perform EUS-HGS. At first, a PS was placed in the choledochojejunostomy route, and a metallic stent was placed across the HGS route due to the incomplete stone extraction because of large stone size [Video 1]. One month later, the PS was revealed to be placed into B2 [Figure 2a]. It seemed to be difficult to retrieve the PS because of embedding into not B3 but B2. After we removed the metallic stent in the HGS route, cholangioscope (Spy-Glass DS; Boston Scientific) was inserted. Although we failed to catch the PS by Spy bite under direct visualization [Video 2], we could successfully grasp the flap of embedded stent and easily retrieve it using a Spy basket [Figure 2b, c and Video 3]. Finally, stones were completely extracted using electrohydraulic lithotripsy with a cholangioscopy. No procedure-related adverse events occurred [Figure 2d]. Although stent dislocation can be a serious complication during interventional EUS and may need surgical intervention, cholangioscopy-guided grasping the flap of PS by Spy basket can be an effective method for retrieval of embedded PS.Figure 2: Retrieval of an embedded stent using a digital cholangioscopy and Spy basket; (a) An embedded plastic stent to the left lateral branch of the bile duct (B2). (b and c) The embedded stent was grasped using a Spy basket under digital cholangioscopic visualization, on the cholangioscopic image and fluoroscopic image. (d) Fluoroscopic image of the biliary duct after removal of the stent and intrahepatic biliary stonesDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Intraluminal endoscopy for biliary duodenal obstruction

Cholelithiasis complicated by cholecystoduodenal fistula and small bowel biliary obstruction is an absolute indication for surgical treatment. Modern possibilities of intraluminal endoscopy (electrohydraulic lithotripsy) made it possible to avoid intra-abdominal access (laparotomy, laparoscopy) and postoperative complications. Finally, rapid rehabilitation was noted.

A case of the use electrohydraulic contact lithotripsy to eliminate the impacted of the endoscopic basket in choledocholithiasis

A case of the use electrohydraulic contact lithotripsy to eliminate the impacted of the endoscopic basket in choledocholithiasis

Impacted gallstone within a cholecystoduodenal fistula: endoscopic laser lithotripsy to the rescue

Video 1A large, impacted gallstone is treated unsuccessfully with electrohydraulic lithotripsy; however, fragmentation and removal is accomplished using endoscopic laser lithotripsy.

OGBN O06 Sharing Experience of SpyGlass™ Discover and ElectroHydraulic Lithotripsy in Treating Large Bile Duct Stone Through the Trans-Cystic Approach During Laparoscopic Cholecystectomy

Abstract Background The one session management of gallstone (GS) disease associated with bile duct stone (BDS) involves laparoscopic cholecystectomy (LC) with bile duct exploration, which remains the gold standard treatment. A two-session management with ERCP followed by laparoscopic cholecystectomy, subjects patients to preventable ERCP related risks including perforation, bleeding, pancreatitis, incomplete clearance and repeat tests, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC-BDE) appears to have less morbidity than Trans-Ductal BDE (TD-BDE). However, large BDS remain the main challenge for the Trans-Cystic (TC) approach, in addition to factors such as, difficult anatomy and proximally located stones. The development in technology and evolving of spyglass DiscoverTM as 3.6mm choledochoscope with Lockable four-way steering and short tip deflection, that could utilize the electrohydraulic lithotripsy (EHL) has made the TC approach to manage large BDS possible. The aim of this abstract is to share our experience in the utilisation of the spyglass discovery TM and SG-EHL in management of large BDS using the TC approach. Methods Data from laparoscopic cholecystectomies performed by a single surgeon in Tayside NHS between 01/07/2020 and 01/06/2022 has been prospectively collected and evaluated. During the study period, 205 laparoscopic cholecystectomies were performed. From the 205 cases, 118 cases were emergency, and 140 cases involved female patients. Spyglass discover TM and SG-EHL were used in four cases, which will be discussed in the results section. Results Cases-1: 39-year-old female with 12mm BDS. Related medical history includes: 1-Right-nephrectomy that was complicated with abdominal abscess 17 years-ago. 2-Failed ERCP that was complicated with necrosis and collection, necessitating an anterior abdominal drain 2 months ago. TC-BDE and clearance was secured with SG-EHL. Abdominal drain for 5-days. Patient discharged home Day 5. Case-2: A 51-year-old male with alcoholic liver cirrhosis and ascending cholangitis due to 17mm BDS and Gallstone. Trial of TC-BDE that was converted to transductal due to friable inflamed cystic-duct and proximal location of BDS at the confluence. Successful SG-EHL helped in minimizing the size of duct opening. Cystic duct biliary drain, and abdominal drain were placed. CD drain was removed after clear tube cholangiography Day 3. Patient developed bile leak that was treated conservatively, and patient discharged after 15-days, abdominal drain was removed after 8-weeks. Case-3: 71-year-old female with 15mm BDS was cleared trans-cystically using SG-EHL. No abdominal drains. Patient had raised inflammatory marker post-surgery treated with antibiotics and patient discharged home Day 4. Case-4: 64-year-old male with12 mm BDS, with previous failed ERCP due to complex duodenal diverticula, TC-BDE and clearance was achieved using SG-EHL LC. Abdominal drain was removed and patient discharge home Day 2. Conclusions This study demonstrates that one session management of large BDS associated with GS, is safe and feasible using trans-cystic approach, with the utilization of the TC approach along with the available technology, the SpyGlass™ Discover and electrohydraulic lithotripsy. Although, the transductal approach might be necessary to ensure bile duct clearance, utilizing SG-EHL might prove beneficial in reducing the size of bile duct opening. Discussion with the patient and informed consent are essential to ensure Patient-specific therapy. A one session management of GS disease should be offered to patients, if indicated, with available support and expertise. More training opportunities in Laparoscopic bile duct exploration is needed to increase the patient's chance of receiving the gold standard treatment for BDS associated with GS.

OGBN P13 Management of Bouveret Syndrome: an endoscopic approach

Abstract Background Bouveret syndrome is rare complication of gallstones with 600 reported cases since 1950. The syndrome occurs when adhesions develop between the gallbladder to surrounding hollow viscera leading to fistula formation. Large gallstones migrate into the enteric system and become impacted in the stomach or duodenum causing gastric outflow obstruction. Bouveret syndrome accounts for 1–4% of gallstone ileus cases. It is more common in co-morbid women in their 7th and 8th decades. Most common symptoms are vomiting and abdominal pain. Upper gastrointestinal bleeding is reported in 15% of cases. CT scan has the highest sensitivity at 79–93% to make the diagnosis. Of note 15–25% of gallstones are isoattenuating. Riglers triad is a diagnostic marker and consists of aerobilia, a gastric outflow obstruction or dilated bowel and the presence of a calculus outside of the biliary tree. The diagnosis was associated with mortality rates as high as 30% but with modern advances mortality has decreased to approximately 12%. Treatment options are surgical or endoscopic retrieval. Endoscopic management carries less risk especially in the frail elderly patient. This approach has low success rates. We present a case of successful endoscopic management of Bouveret syndrome and discuss surgical and endoscopic management strategies. Methods A frail 83 year old female attended ED with epigastric pain, vomiting and signs of sepsis. She had a recent diagnosis of severe cholecystitis that was managed conservatively. On examination she had tenderness in the right upper quadrant. Bloods revealed an AKI, a CRP 189 and normal liver function tests. Axial imaging showed aerobilia with a CBD dilated at 14mm and there was a 3.5cm calculus impacted in the duodenum with a cholecysto-duodenal fistula. Her medical history included diabetes mellitus, atrial fibrillation, hypertension, primary hyperparathyroidism, reflux and cauda equina (operated). On OGD there was a large stone which had eroded into the first part of the duodenum. A combination of mechanical lithotripsy and the Kudo snare were used to fragment the stone. 2 large fragments were retrieved using a bag to avoid gallstone ileus. Results The patient had an uneventful but slow recovery. She re-established oral intake on the second post-operative day. She was discharged 2 weeks later without complication. Conclusions The success of endoscopic management is reported as low as 10%. Endoscopic intervention is attempted in 61% of cases. Success is more likely with stones <4cm and if the site of impaction is the stomach or D1/D2. Surgical management is associated with a morbidity rate of 26% but was successful in 78%. Laparoscopic surgery is possible but less successful in stones >5cm. Endoscopic techniques have evolved and should be considered for extraction of stones in the first instance. If not feasible surgery can be considered. The literature shows that success is more likely when various endoscopic techniques are utilized including mechanical lithotripsy, nets and baskets, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, laser lithotripsy and duodenal stenting. There is a risk of distal migration of stone fragments causing gallstone ileus in the more distal small bowel. Bouveret syndrome can be resolved with endoscopy in expert hands.

OGBN P09 Sharing the experience of the use of Spyglass DS - guided electrohydraulic lithotripsy (SG-EHL) in the treatment of large gallstone causing Bouveret syndrome

Abstract Background Less than 1% of intestinal obstruction is accounted for by gallstone ileus. Gallstone ileus is a mechanical intestinal obstruction resulting from gallstone impaction within the gastrointestinal tract. Under 3% of gallstone ileus are caused by gallstone impaction in the duodenum or pylorus, which can give rise to a gastric outlet obstruction, described by Bouveret in 1896. Surgical intervention involves the removal of the stone by either a gastrotomy or duodenotomy, which is associated with significant morbidity. Advancement in endoscopic techniques, allows for more complex procedures, therefore, reducing the need for a surgical intervention and its accompanying morbidity. This abstract presents a rare case of a large gallstone (22mm×34mm) partially impacted in the duodenum of a 92-year-old female, which was treated with the Spyglass DS-guided electrohydraulic lithotripsy (DS-EHL). Methods A 92-year-old female with a previous history of gallstone ileus was treated by surgical intervention. The patient continued to complain of abdominal discomfort and occasional vomiting. A CT scan revealed a fistulous communication to the duodenal bulb, containing a large gall stone (22mm x34 mm). After consultation with the patient, an initial assessment with the use of standard endoscopy under general anaesthesia confirmed the visualisation of a portion of the gallstone in the duodenum, hanging through a well-established cholecysto-dudenal fistula. SPyglass DS - guided lithotripsy (SG-EHL) was used in the treatment of the large gallstone. Results Electrohydraulic lithotripsy (EHL) was attempted through the standard gastroscope, but we were unable to secure a safe position to target the stone. Therefore, a side view duodenoscope was used along with the SpyGlass DS to obtain good visualisation and stable access to target the stone with the EHL. The Spyglass guided electrohydraulic lithotripsy (SG-EHL) was used to fragment the stone. Despite consuming four EHL wires and using higher settings, we only managed to break the shell of the stone, reducing its size by approximately 3mm all around. The laser was not available at the time; therefore, the procedure was concluded. The patient had an uneventful recovery and was discharged home. No further symptoms were recorded by patient on follow up 5 months later. Conclusions Endoscopic management of an impacted gallstone causing gastric outlet obstruction is found to be safe and carries less morbidity than the traditional surgical approach. Therefore, it should be considered for being the procedure of choice to treat patients with Bouveret syndrome. Laser lithotripsy should be available on standby for cases that involve stones that are harder to break.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

Single-balloon-assisted endoscopy with peroral pancreatoscopy and electrohydraulic lithotripsy.

A case of pancreatic duct stones treated with electrohydraulic lithotripsy through a duodenal ulcer.

Video 1Crush the large-sized stones directly using an electrohydraulic lithotripsy device.

Intractable Pancreatic Stone Removal Using SpyGlass™ DS II with Electrohydraulic Lithotripsy: A Case Report and Literature Review

Pancreatic stones are a common finding of chronic pancreatitis and may causerecurrent abdominal pain and pancreatitis. Pancreatic stones are often accompaniedby stenosis of the pancreatic duct and are often impacted within the pancreaticduct, so it is not easy to remove the pancreatic stones using a basket. Until now,extracorporeal shock wave lithotripsy has been used, but it requires repeatedprocedures and the success rate is not very high. The recently developed SpyGlass™DS II (Boston Scientific, Marlborough, MA, USA) has a 3.5 mm diameter that allowsinsertion into the dilated pancreatic duct, it is possible to remove the pancreaticstones using electrohydraulic lithotripsy (EHL) or laser lithotripsy while directlyviewing the pancreatic stones. In this paper, we would like to introduce a method toremove multiple pancreatic stones larger than 10 mm using SpyGlass™ DS II with EHL.

Single-operator Cholangioscopy Guided Lithotripsy

ERCP is the standard treatment for common bile duct stones (CBD stones). On the other hand, in approximately 10% of patients with CBD stones, the complete removal of the stones cannot be achieved by conventional ERCP, which performs endoscopic sphincterotomy followed by stone extraction. Additional advanced and complex procedures are often necessary to remove these "difficult bile duct stones", including endoscopic papillary large balloon dilatation or mechanical lithotripsy. Advances in cholangioscopy have made electrohydraulic or laser lithotripsy under direct endoscopic visualization possible during ERCP. Cholangioscopy-guided lithotripsy using the SpyGlass DS system could be a better treatment tool for removing difficult stones. The focus of this review was to describe single-operator cholangioscopy in the management of difficult CBD stones.