Electrohydraulic lithotripsy using peroral cholangioscopy for impaction of stent-stone complex around biliary plastic stent

A stent-stone complex is a rare complication of long-term placement of biliary plastic stents [1] [2]. Stones form around the proximal end of the stent, making endoscopic removal of the stent difficult. Herein we report a case of successful endoscopic removal of a stent-stone complex using peroral cholangioscopy-guided electrohydraulic lithotripsy (EHL).

An 80-year-old woman was referred to our hospital for treatment of large bile duct stones (35 mm) ([Fig. 1]). Peroral cholangioscopy-guided EHL was performed; however, stones could not be completely removed, and a plastic stent was placed ([Fig. 2]). Two months after peroral cholangioscopy-guided EHL, a 30-mm stent-stone complex formed ([Fig. 3 a]). We attempted to remove the stent-stone complex with grasping forceps; however, it could not be moved, and the plastic stent broke off at the grasping site ([Fig. 3 b]). We performed EHL again under peroral cholangioscopy (SpyScope DS II; Boston Scientific, Tokyo, Japan) for stent-stone complex extraction ([Video 1]). A stent-stone complex resembling a lollipop was observed in the distal bile duct ([Fig. 3 c]). The stone was fixed by the stent; this allowed the shock waves to be applied efficiently. The time taken to crush the stones around the plastic stent was approximately 10 min. The stones were then removed using a balloon catheter ([Fig. 3 d]). Balloon cholangiography after stone evacuation confirmed complete removal of the stones ([Fig. 3 e]). The patient recovered without cholangitis or bile duct stone recurrence.

Fig. 1 Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) images before the procedures. a Coronal view on CT showed a large stone in the common bile duct. b MRCP showed a defect suggestive of a 32-mm stone at the junction of the cystic duct and the common bile duct.

Fig. 2 The first electrohydraulic lithotripsy (EHL) under endoscopic retrograde cholangiopancreatography (ERCP). a ERCP showed a huge translucent filling defect in the common bile duct. b, c The presence of a yellow stone was confirmed by cholangioscopy and EHL was performed. d After EHL, the stones were removed with a balloon catheter; however, it was difficult to remove them completely.

Fig. 3 The second electrohydraulic lithotripsy (EHL) under endoscopic retrograde cholangiopancreatography (ERCP) for removal of the stent-stone complex. a The stent-stone complex was formed. b The stent was broken off during removal. c EHL was performed for stent-stone complex removal. d The stones were crushed for only approximately 10 minutes. e The stones were removed with a balloon catheter, and cholangiography confirmed that there were no residual stones.

Video 1 The procedure of electrohydraulic lithotripsy using peroral cholangioscopy for removal of a stent-stone complex.

Endoscopic removal of a stent-stone complex is difficult, and forcible extraction of a large stent-stone complex can cause papillary injury or biliary perforation. Further, surgery for a stent-stone complex [3] [4] is highly invasive. In this case, EHL under peroral cholangioscopy efficiently crushed the stent-stone complex because the plastic stent served as an anchor. We believe that peroral cholangioscopy-guided EHL is an extremely useful method for stent-stone complex removal.

Endoscopy_UCTN_Code_TTT_1AR_2AH

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Tang SJ, Armstrong L, Lara LF. et al. De novo stent-stone complex after long-term biliary stent placement: pathogenesis, diagnosis, and endotherapy. Gastrointest Endosc 2007; 66: 193-200
• 2 Morimachi M, Ogawa M, Yokota M. et al. Successful endoscopic removal of a biliary stent with stent-stone complex after long-term migration. Case Rep Gastroenterol 2019; 13: 113-117
• 3 Barai V, Hedawoo J, Changole S. Forgotten CBD stent (102 months) with stone-stent complex: a case report. Int J Surg Case Rep 2017; 30: 162-164
• 4 Upwanshi MH, Shaikh ST, Ghetla SR. et al. De novo choledocholithiasis in retained common bile duct stent. J Clin Diagn Res 2015; 9: PD17-PD18

Publication History

Article published online:
05 July 2022