Electrohydraulic lithotripsy for the treatment of stone impacted in a lumen-apposing metal stent in a patient with endoscopic cholecystoduodenostomy

An 89-year-old woman presented to our department having experienced acute cholecystitis a few weeks previously. Her comorbidities, chronic kidney disease, and congestive heart failure meant she was not a suitable candidate for surgery. She underwent EUS-guided gallbladder drainage, which was performed without complications. During this procedure, a 10-mm × 10-mm lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific) was implanted for gallbladder drainage. A few days later, the patient complained of right-upper quadrant abdominal pain and fever, and a new acute cholecystitis episode was diagnosed.

Upper endoscopy with a therapeutic endoscope (GIF-1TH190; Olympus) was performed. The endoscope was introduced as far as the duodenum, where it became evident that the LAMS was obstructed by a biliary stone impacted in the stent lumen ([Fig. 1]; [Video 1]). Electrohydraulic lithotripsy (EHL) (1.9-Fr, 375-cm Biliary EHL Probe Autolith; Boston Scientific) was performed to fragment the obstructive biliary stone. The EHL probe was introduced through the endoscope, and fragmentation with the infusion of saline was started ([Fig. 2]). The gallbladder stone was broken into multiple fragments that were removed with a Dormia basket. During the procedure, which lasted about 60 min, purulent secretion was seen draining from the gallbladder. The gallbladder wall showed a 10 mm-fistula with some fragmented stones within the cavity ([Fig. 3]); these were removed with a Roth Net retriever. To prevent renewed LAMS occlusion, placement of a plastic double-pigtail stent was decided on ([Fig. 4]). No complications were observed in the patient; she tolerated the procedure and was discharged home a few days later.

Fig. 1 Lumen-apposing metal stent (LAMS) obstructed by a biliary stone impacted in the stent lumen.

Video 1 Biliary stone occluding a lumen-apposing metal stent treated with electrohydraulic lithotripsy in a patient who had previously undergone endoscopic ultrasound-guided cholecystoduodenostomy.

Fig. 2 Fragmentation of biliary stone by means of electrohydraulic lithotripsy.

Fig. 3 A 10-mm fistula in the gallbladder wall with fragmented stones in the cavity.

Fig. 4 Placement of a plastic double-pigtail stent to prevent renewed occlusion.

EUS-guided gallbladder drainage in patients who are not candidates for surgery is a safe technique and has a low complication rate. In patients with large stones, recurrent cholecystitis, impaction, and LAMS obstruction can occur [1] [2]. EHL and laser lithotripsy are two useful techniques that allow fragmentation of stones; EHL generates high-amplitude hydraulic pressure waves, while laser lithotripsy uses a laser beam with repetitive pulses of laser energy to create a mechanical shockwave [3] [4]. EHL is a safe option to resolve LAMS occlusion in cholecystoduodenostomy.

Endoscopy_UCTN_Code_CPL_1AL_2AD

Publication History

Article published online:
14 January 2021

• References

• 1 Anderloni A, Buda A, Vieceli F. et al. Endoscopic ultrasound-guided transmural stenting for gallbladder drainage in high-risk patients with acute cholecystitis: a systematic review and pooled analysis. Surg Endosc 2016; 30: 5200-5208
• 2 Nasser A, Bill K, Barawi M. Lumen-apposing metal stent–assisted electrohydraulic lithotripsy and mechanical lithotripsy for cholelithiasis in a nonsurgical patient. VideoGIE 2019; 4: 159-160
• 3 Sievert C, Silvis S. Evaluation of electrohydraulic lithotripsy as a means of gallstone fragmentation in a canine model. Gastrointest Endosc 1987; 33: 233-235
• 4 Hochberger J, Gruber E, Wirtz P. et al. Lithotripsy of gallstones by means of a quality-switched giant-pulse neodymium: yttrium-aluminum-garnet laser. Basic in vitro studies using a highly flexible fiber system. Gastroenterology 1991; 101: 1391-1398