EUS guided fine needle fragmentation (EUS-FNF) for the treatment of difficult biliary stones; a novel therapeutic indication for EUS. A case report with images

Aims This case reports a novel therapeutic indication for EUS in difficult biliary stone disease.

Methods A lady (65y) presented with abdominal pain and jaundice. The liver enzymes, ALP and bilirubin were elevated. MRCP showed Mirrizi’s syndrome Type I. An impacted stone in the cystic duct was obstructing a very short common hepatic duct and the intrahepatic biliary tree. A cholangiogram in the laparoscopic cholecystectomy with intraoperative ERCP confirmed the MRCP finding. The surgeon was unable to mobilize the stone out of the cystic duct. A transcystic guide wire was provided to an ERCPst and a balloon was introduced to the cystic duct by the ERCPst. The stone could not be mobilized to the common bile duct. The cystic stone was left and the bile duct was stented with a plastic stent.

Results Two weeks later, the patient was readmitted for an elective stone extraction with cholangioscopy and lithotripsy. Based on a personal experience of fragmenting a pancreatic stone using FNA-needle, the endoscopist decided to start with EUS.

The stone in the cystic duct was found on EUS and confirmed by a cholangiogram using a 25G EUS-FNA needle. The stone was fragmented by the needle and flushed into the common hepatic duct. Only an ERCP and a balloon catheter were then used to extract the stone in the same session. No further stones were observed on the final cholangiogram.

Conclusions EUS guided fine needle fragmentation (EUS-FNF) seems to be an easy, effective and cheap new therapeutic indication for EUS.

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Artikel online veröffentlicht:
14. April 2023