Combined endoscopic lithotripsy and percutaneous transhepatic cholangioscopy therapy for refractory choledocholithiasis

A 39-year-old man who had undergone choledochojejunostomy with Roux-en-Y reconstruction for congenital biliary dilatation was referred to our hospital with choledocholithiasis. Computed tomography revealed large bile duct stones (BDS) in the hilum ([Fig. 1] a). BDS removal was attempted using a double-balloon enteroscope (DBE); however, it failed to crush the BDS, especially those in the right hepatic duct branch ([Fig. 1] b). Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy was performed; however, complete stone clearance was not achieved because of the limited range of motion of the cholangioscope caused by the BDS. Therefore, combined therapy comprising endoscopic lithotripsy and percutaneous transhepatic cholangioscopy was planned to maximize the effects of cholangioscopy with the support of the DBE ([Fig. 2], [Video 1]).

Fig. 1 Images showing multiple large bile duct stones in the hilum. a Computed tomography. b Cholangiography.

Fig. 2 Schematic diagram of combined approach. a Endoscopic lithotripsy under cholangioscopic monitoring. b Percutaneous transhepatic cholangioscopy for bile duct stones for which endoscopic lithotripsy was difficult (circle). c Efficient stone removal through simultaneous water delivery from the cholangioscope and absorption via the endoscope.

Combined therapy comprising endoscopic lithotripsy and percutaneous transhepatic cholangioscopy for refractory choledocholithiasis.Video 1

Endoscopic stone removal was performed under cholangioscopic guidance. Subsequently, percutaneous transhepatic cholangioscopy was attempted for BDS that could not be removed by endoscopic lithotripsy; however, multiple small residual stones were identified during cholangiography. Therefore, stone removal from the anastomosis to the jejunum was performed using the force of water distributed from the biliary speculum and endoscopic aspiration. The BDS were efficiently removed from the anastomosis, and complete stone clearance was achieved ([Fig. 3]).

Fig. 3 Images showing complete stone clearance. a Computed tomography. b Cholangiography.

Although percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy is a useful treatment for refractory BDS [1] [2] [3], stone clearance can be difficult when the working space for the cholangioscope is limited by large stones. An advantage of combined therapy comprising endoscopic lithotripsy and percutaneous transhepatic cholangioscopy is that different approaches using the endoscopic and percutaneous routes during the same session can performed in difficult areas, thereby reducing the procedure time. This method allows efficient stone removal using water delivery from the cholangioscope and water absorption via the DBE.

In conclusion, combined therapy comprising endoscopic lithotripsy and percutaneous transhepatic cholangioscopy is useful for refractory BDS.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Binmoeller KF, Brückner M, Thonke F. et al. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993; 25: 201-206
• 2 Mo LR, Hwang MH, Yueh SK. et al. Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy (PTCS-EHL) of common bile duct stones. Gastrointest Endosc 1988; 34: 122-125
• 3 Kurihara T, Yasuda I, Isayama H. et al. Diagnostic and therapeutic single-operator cholangiopancreatoscopy in biliopancreatic diseases: prospective multicenter study in Japan. World J Gastroenterol 2016; 22: 1891-1901

Publication History

Article published online:
17 December 2024