TRANSHEPATIC CHOLANGIOSCOPY-GUIDED ELECTROHYDRAULIC LITHOTRIPSY FOR LARGE COMMON BILE DUCT STONE AND ANTEGRADE DUCTAL CLEARANCE IN A PATIENT WITH DIFFICULT TRANSPAPILLARY ACCESS

Aims We are reporting an innovative approach of managing large common bile duct stone through transhepatic route in a patient with inaccessible transpapillary cannulation.

Methods Care report: A 50 years female with abdominal pain, jaundice, and a large CBD stone on imaging underwent duodenoscopy which revealed a large periampullary diverticulum filled with semi-solid food particles. Ampulla was completely buried in the diverticula and could not be located so percutaneous transhepatic drainage (PTBD) was performed. Percutaneous transhepatic cholangioscopy (PTHC) was performed after 2 weeks through a mature bilio-cutaneous fistula under sedation in the prone position. A novel cholangiscope was inserted after replacing the PTBD catheter with an 11 French sheath and electrohydraulic lithotripsy (EHL) was performed and satisfactory fragmentation was achieved after 600 shocks. The CBD clearance was achieved after performing antegrade sphincteroplasty and extractor balloon sweeps.

Results In our case transpapillary approach was not possible so opted for PTHC instead of surgery. As the track was already 2 weeks mature so 11 French sheath was easily passed followed by easy entry of cholangioscope. The stone was easily fragmented after 600 shocks at low energy and frequency. Antegrade sphincteroplasty and balloon sweeps were also easy as was the occlusion cholangiogram. The only drawback of this technique is that intrahepatic ducts balloon sweeps require a conventional retrograde approach and increase the time of the procedure.

Conclusions This case signifies that transhepatic cholangioscopy guided EHL is a viable, safe, and effective therapeutic modality in eligible patients.

Publication History

Article published online:
14 April 2022