Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed for patients
with common bile duct (CBD) stones. Many cases are successfully managed with endoscopic
sphincterotomy and stone removal using balloon or basket catheters. However, for difficult
or complex stones, ERCP with conventional techniques may fail to achieve biliary clearance
in 10–15% of cases [1]. Peroral cholangioscopy-guided electrohydraulic lithotripsy (POCS-EHL) is effective
in these cases; however, it is expensive and time-consuming. Herein, we report a case
of endoscopic lithotripsy for an impacted stone at the confluence of the cystic duct
(CD) and CBD using a novel drill dilator.
A 77-year-old woman with a high fever and abdominal pain was admitted to our institution.
Blood tests showed obstructive jaundice, and computed tomography revealed a common
bile duct stone ([Fig. 1]). ERCP revealed the stone was present at the confluence of the CD and CBD ([Fig. 2]
a). Although stone removal using a mechanical lithotriptor (LithoCrush V; Olympus Medical
Systems, Tokyo, Japan) was attempted, it was difficult to catch and crush the stone
because of the narrow working space ([Fig. 2]
b). Although POCS-EHL is an alternative procedure, it is not regularly performed in
our institution. Therefore, endoscopic lithotripsy was performed using a novel drill
dilator (Tornus ES; ASAHI INTECC, Aichi, Japan and Olympus Medical Systems, Tokyo,
Japan) for the confluence stone. With a clockwise rotation, the drill dilator could
be passed through, while chipping away at the stone, without requiring a strong pushing
force. The stone was completely removed using conventional basket and balloon catheters
during a single ERCP session ([Fig. 3], [Video 1]). It is thought that the twisting force of the drill dilator was easily transmitted
to the impacted stone, which has poor mobility, leading to lithotripsy.
Fig. 1 Computed tomography (CT) images. CT revealed a common bile duct stone.
Fig. 2 Fluoroscopic images. a Endoscopic retrograde cholangiopancreatography (ERCP) revealed the stone was present
at the confluence of the cystic duct (CD) and common bile duct (CBD). b It was difficult to catch and crush the stone using a mechanical lithotriptor because
of the narrow working space.
Fig. 3 Fluoroscopic images. a Endoscopic lithotripsy using a novel drill dilator. b Stone removal using a basket catheter. c Biliary clearance using a balloon catheter.
Endoscopic lithotripsy for an impacted biliary stone at the confluence of the cystic
duct and common bile duct using a novel drill dilator.Video 1
Endoscopic lithotripsy using a novel drill dilator is useful in patients with an impacted
biliary stone at the confluence of the CD and CBD.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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