Cystic duct stump stone removal by retrieval basket under direct visualization using a novel peroral choledochoscope

Calculus in a cystic duct remnant is one of the causes of postcholecystectomy syndrome. Surgical extraction of the stone with excision of the cystic duct can be carried out, but the adhesions caused by the prior operation make the reoperation more challenging [1]. Endoscopic retrograde cholangiopancreatography (ERCP) has been used to extract the stone in combination with lithotripsy [2] [3] [4], but is confined to only a small subset of patients. We present a novel peroral choledochoscope (Eye-Max CDS11001; Micro-Tech, China) with a 1.8-mm working channel to introduce therapeutic equipment ([Fig. 1]).

Fig. 1 The peroral choledochoscope and the retrieval basket.

A 69-year-old man experienced right upper quadrant abdominal pain on the 5th day after laparoscopic cholecystectomy. ERCP showed an 8 mm × 8 mm filling defect in the cystic duct stump ([Fig. 2]), suggesting a retained stone. Because of the limited stump length, attempts to grab the stone by retrieval basket and balloon both failed. A peroral choledochoscope was used for further exploration ([Video 1]). When the digital catheter reached the cystic duct, a dark brown stone was seen in the cystic duct stump ([Fig. 3]). A four-wire retrieval basket (CEB01010, open diameter 15 mm; Micro-Tech (Nanjing) Co., P. R. China) was then inserted into the bile duct through the working channel of the peroral choledochoscope. Under direct visualization, the stone was successfully grasped with the basket ([Fig. 4]). The stone was cautiously pulled into the common bile duct and then the duodenum. Repeat cholangiography showed no stones retained. The patient was discharged without further event after 5 days.

Fig. 2 Cholangiography showed an 8 mm × 8 mm filling defect in the cystic duct stump.

Video 1 Removal of a stone in the cystic duct stump using a retrieval basket under direct visualization by a novel peroral choledochoscope.

Fig. 3 Visualization of the stone in the cystic duct stump through the peroral choledochoscope.

Fig. 4 The stone grasped by the retrieval basket.

We present a new endoscopic technique for minimally invasive extraction of a stone or stones in a cystic duct remnant, thus avoiding a second surgical operation. More cases and longer follow-up are needed to validate the advantage of this technique.

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Competing Interest

The authors declare that they have no conflict of interest.

• References

• 1 Kar A, Gulati S, Mohammed S. et al. Surgical management of cystic duct stump stone or gall bladder remnant stone. Indian J Surg 2018; 80: 284-287
• 2 Benninger J, Rabenstein T, Farnbacher M. et al. Extracorporeal shockwave lithotripsy of gallstones in cystic duct remnants and Mirizzi syndrome. Gastrointest Endosc 2004; 60: 454-459
• 3 Shelton JH, Mallat DB. Endoscopic retrograde removal of gallbladder remnant calculus. Gastrointest Endosc 2006; 64: 272-273
• 4 McCarty TR, Gulati R, Rustagi T. Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: a systematic review and meta-analysis. Endoscopy 2021; 53: 110-122

Publication History

Article published online:
10 October 2022