Endoscopy 2017; 49(10): 1008-1009
DOI: 10.1055/s-0043-113815
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Cholangioscopy-directed lithotripsy for a large bile duct stone: the “donut technique”

Noor L. H. Bekkali
GI services, Pancreato-biliary diseases, University College London Hospitals, London, UK
,
Sham Direkze
GI services, Pancreato-biliary diseases, University College London Hospitals, London, UK
,
George J. M. Webster
GI services, Pancreato-biliary diseases, University College London Hospitals, London, UK
› Author Affiliations
Further Information

Publication History

Publication Date:
18 July 2017 (online)

Conventionally, choledocholithiasis is managed by endoscopic retrograde cholangiopancreatography (ERCP), and it accounts for at least 50 % of the approximately 52 000 ERCPs performed in the UK each year [1] [2] [3] [4] [5]. Bile duct stone clearance traditionally involves the performance of ERCP with biliary sphincterotomy (or sphincteroplasty), followed by the removal of stones from the biliary tree using an extraction balloon, with or without the use of a basket or mechanical lithotripter. Stones may be difficult to remove at ERCP owing to a range of factors, including size (e. g. stones > 15 mm), number, location (e. g. intrahepatic or within the cystic duct), and other anatomical factors (e. g. stones above strictures).

Cholangioscopy was first introduced in 1975 as a dual-operator “mother – baby” technique and allowed direct visualization of intraductal stones and fragmentation of stones with laser or electrohydraulic lithotripsy (EHL). The technique fell out of widespread use because of technical and endoscopic limitations. In 2006, a single-operator cholangioscope was introduced (Spyglass; Boston Scientific Inc., Natick Massachusetts, USA), which reinvigorated the use of cholangioscopy in the management of difficult bile duct stones. In 2015, a second-generation Spyglass cholangioscope (Spyglass DS; Boston Scientific Inc.) was developed, with improved visualization and scope movement, and a larger (1.3 mm) working channel.

Here we report the case of a 46-year-old woman who underwent cholangioscopy for an impacted 3-cm common bile duct stone after three failed conventional ERCPs at her local hospital. We elected to perform an ERCP combined with cholangioscopy. Despite visually directed EHL, the stone could not be cracked, and therefore a tunnel was created through the stone ([Fig. 1]), as shown in [Video 1]. This allowed a wire to be passed through the stone, which was then cracked using a dilating balloon. Subsequent uncomplicated stone clearance followed, with successful bile duct clearance.

Zoom Image
Fig. 1 Cholangiogram showing the cholangioscope passing through the tunnel created with the electrohydraulic lithotripsy probe.

Video 1 Endoscopic retrograde cholangiopancreatography (ERCP) for a large bile duct stone. Cholangioscopy-guided electrohydraulic lithotripsy is performed along with subsequent expansion of a biliary balloon within a tunnel created through the stone to crack and then fragment it.


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  • References

  • 1 Everhart JE, Ruhl CE. Burden of digestive diseases in the United States Part III: Liver, biliary tract, and pancreas. Gastroenterology 2009; 136: 1134-1144
  • 2 Everhart JE, Khare M, Hill M. et al. Prevalence and ethnic differences in gallbladder disease in the United States. Gastroenterology 1999; 117: 632-639
  • 3 Ko CW, Lee SP. Epidemiology and natural history of common bile duct stones and prediction of disease. Gastrointest Endosc 2002; 56: S165-S169
  • 4 McHenry L, Lehman G. Difficult bile duct stones. Curr Treat Options Gastroenterol 2006; 9: 123-132
  • 5 Baillie J, Testoni P-A. Are we meeting the standards set for ERCP?. Gut 2007; 56: 744-746