MANAGEMENT OF COMPLICATED BILIARY STONES USING SPYGLASS DS PER-ORAL CHOLANGIOSCOPY-GUIDED LASER LITHOTRIPSY

Here we report a video-case of an 88-year-old woman referred to our unit because of cholangitis in cholecysto-choledochal lithiasis, deemed unfit for surgery (cholecystectomy) due to severe co-morbidities. Endoscopic retrograde cholangiography (ERC) (TJF-160VR; Olympus Co., Tokyo, Japan), performed under deep sedation with anesthesiological assistance, showed severe dilation of biliary tree with a voluminous stone (about 35 mm) impacted in the common hepatic duct. The endoscopic approach was challenging because of the site, the size of the stone and the overall biliary tree dilation. In fact, because of similar dilation of cystic and common bile duct, it was quite difficult to reach the common hepatic duct.

Thus, single-operator per-oral digital cholangioscopy using SpyGlass DS was performed. The stone was completely fragmented using a 200 micron laser fiber holmium:YAG (Ho:YAG) (frequency 25 – 35 W) (VersaPulse P20, Lumenis Ltd., Yokneam, Israel). The procedure took about 130 minutes to achieve complete biliary drainage.

SpyGlass DS allowed an adequate view of the entire obstructive stone, especially during laser lithotripsy, avoiding biliary duct walls trauma. All the stone fragments were removed using Dormia basket (Basket Hard Type, Olympus EndoTherapy, Tokyo, Japan) or Fogarty-balloon (ExtractorPro XL 15 – 18 mm, Boston Scientific, USA). No complication occurred and the patient was discharged asymptomatic 5 days later.

In conclusion, SpyGlass DS represents a useful diagnostic and therapeutic tool. In case of complicated biliary stones, per-oral cholangioscopy-guided laser lithotripsy can avoid more invasive or surgical interventions.