The Jolting Method: An Efficient Method for Extracting Multiple Common Bile Duct Stones Completely in a Single Procedure

Endoscopic retrograde cholangiopancreatography (ERCP) is used to treat common bile duct stones, but it should be performed a minimum number of times due to high incidence of serious complications.[1] [2] Cholesterol stones are known to be aggregates of multiple stones, and their hard texture can cause clogging if a basket grabs a large amount at once, leading to the need for invasive procedures such as surgery.[3] Therefore, these stones must be carefully removed in small amounts, which can be an extremely time-consuming process that requires multiple procedures. In this report, we developed the new method, which can efficiently and completely remove a large number of cholesterol stones in a single procedure.

An 82-year-old male patient with cholangitis caused by a significant number of cholesterol stones that completely filled bile duct was treated with stent placement. After improvement of the cholangitis, we proceeded with ERCP to remove the stones. After the removal of the bile duct stent, an additional endoscopic sphincterotomy was performed with a papillotome (CleverCut 3V, Olympus, Tokyo, Japan). Following this, a dilatation balloon (REN 0.035 10–12 mm, Kaneka Medics, Osaka, Japan) was carefully inserted into the bile duct and gradually inflated to prevent the entrapment of stones. Considering the risk of basket entrapment, the stones were carefully extracted with a retrieval balloon (Multi-3 V Plus, Olympus, Tokyo, Japan), starting from the lower end of the bile duct. Despite repeated balloon sweeping, a significant number of stones remained. At that point, we decided to perform “the jolting method.” [Supplementary Video S1] While the retrieval balloon was extracted toward the papilla, it was then carefully “jolted” at sites of resistance. This motion resulted in the sequential expulsion of stones. By repeatedly applying this method, we were able to successfully remove all stones from the common bile duct during a single procedure ([Fig. 1]).

Fig. 1 Multiple stacked cholesterol stones were identified through magnetic resonance cholangiopancreatography (A) and endoscopic retrograde cholangiography (B). The jolting method can efficiently and completely remove a large number of cholesterol stones in a single procedure (C, D).

Technical Highlights

When performing the endoscopic large balloon dilatation, balloon was carefully inserted into the bile duct, gradually inflating to prevent the potential entrapment of stones.

Considering the risk of basket entrapment, the stones were carefully extracted with a retrieval balloon from near the papilla.

The retrieval balloon was extracted toward the papilla, and then carefully “jolted” at sites of resistance. This motion resulted in the sequential expulsion of stones.

Conclusions

The jolting method enables the efficient extraction of multiple stacked cholesterol stones in a single procedure.

Conflicts of Interest

None declared.

Author Contribution

S.I. and M.K. study design and collection of data and writing of the manuscript; M.K. data analysis/interpretation; R.O. study supervision.

• References

• 1 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52 (02) 127-149
• 2 Christoforidis E, Vasiliadis K, Tsalis K. et al. Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with “difficult” choledocholithiasis: a single-center experience. Diagn Ther Endosc 2014; 2014: 861689
• 3 Kucharski K, Adler DG. Comparison of technical failures and patient-related adverse events associated with 3 widely used mechanical lithotripters for ERCP: insights from the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience database. Gastrointest Endosc 2022; 96 (05) 796-800

Publication History

Article published online:
28 December 2023