ELECTROHYDRAULIC LITHOTRIPSY IN CASE OF SEVERE BILE DUCT STONES AFTER BILROTH-II

Patient, male, 76 years old, addmitted to our hospital with diagnosis: bile stone disease, obstructive jaundice with bilirubin 21 mg/dl, bile duct stones with biliary hypertension. Bilroth-II stomach resection due to ulcer bleeding 30 years ago. Common bile duct – 20 mm, common hepatic duct – 15 mm, cystic duct – 8 mm. Multiple bile duct stones of barrel and cubic shape, 25*20 mm in size. According to our experience, side-viewing duodenoscope is not a best choice in Bilroth-II cases. We performed duodenoscopy with forward-viewing HD-scope, canulated papilla, initiated cholangiography. We performed sphincerotomy with a sphincterotome, developed for reverse EST in Bilroth-II cases. Barrel-shaped triangular and cubic stones are the most challenging for endoscopic extraction. So, we failed to treat patient in routine way. Further methods of treatment offered: extracorporal distant shockwave lithotripsy, percutaneous transhepatic drainage, surgery and endoscopic choledohoscopy with direct lithotripsy. Endoscopt seemed to be the most balanced between risks and benefits of treatment. We repeated duodenoscopy with standart forward-looking 9 mm diameter HD-scope with instrumental channel 2.8 mm. As EST was already performed we could easily enter the bile duct with the scope. Cholangioscopy was performed wth water filling and without gas inflation. We visualised bile duct stones and crushed them with direct contact electrohydraulic lithotripsy with WALZ system. The procedure took onr hour and 20 minutes. The procedure was performed with propofol sedation in our ERCP room.

Patient was discharged from hospital after 5 days with significant condition improvement. No signs of residual bile duct stones and no postoperative complications.

Direct contact electrohydraulic lithotripsy is effective and safe method in treatment of severe bile duct stones, especially in difficult anatomical and clinical situations. In Bilroth-II cases this technic can replace cholangioscopy with a very special devices.