ADVANCED CHOLANGIOSCOPY GUIDED LITHOTRIPSY IN 2 PATIENTS WITH COMPLEX BILIARY STONES

Description:

ERCP is the first-line technique for the treatment of biliary stones. Most stones are successfully removed using extraction balloons and/or Dormia baskets, and in more complex cases, using mechanical lithotripsy and/or balloon dilation of the ampulla after sphincterotomy. There are, however, a small group of patients with complicated stones, in which these techniques are not effective.

In this video, we present 2 patients with highly complex biliary stones referred for single operator peroral cholangioscopy (Spyglass DS)-guided lithotripsy.

The first case was a 91-year-old woman with multiple previous episodes of cholangitis, with 2 large stones in the bile duct, sizes 20 and 40 mm, with the latter impacted at the common hepatic duct. The patient underwent a total of three ERCP sessions, the first with electrohydraulic lithotripsy (EHL), and the second with Holmium laser lithotripsy (LL). In the third and last session, the treatment was completed with the removal of the residual stones.

The second case corresponds to a 70-year-old male with an indeterminate stenosis of the common hepatic, in which SpyGlass DS allowed not only to achieve the correct diagnosis (Mirizzi syndrome), but also to perform laser holmium lithotripsy.

Motivation:

The introduction of Spyglass DS allowed the routine use of EHL and LL. These advanced lithotripsy techniques have demonstrated a high efficacy and safety in the fragmentation of complex biliary stones, as suggested by a few cohorts and case series recently published. With this video we intend to demonstrate the usefulness of EHL and LL, assisted by Spyglass DS, in 2 different clinical scenarios, highlighting details of the technical execution that increase the odds of success and safety of the procedure. The lithotripsy of the 40 mm stone, is the largest stone reported in video, using advanced lithotripsy techniques assisted by single operator per-oral cholangioscopy.