Gel-immersion electrohydraulic lithotripsy during digital single-operator cholangioscopy is helpful when bleeding occurs

Electrohydraulic lithotripsy (EHL) during digital single-operator cholangioscopy (dSOC) is a useful technique for difficult bile duct stones [1] [2]; however, visibility during dSOC can be poor in the presence of bleeding or infected bile juice. In such situations, EHL may be challenging. The use of gel-immersion endoscopy using a transparent gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan), which is more viscous than saline ([Fig. 1]), has recently been reported as a method for securing the visual field [3] [4] [5]. Use of the gel-immersion technique has not yet been reported in the pancreaticobiliary endoscopic field. We herein describe technical tips for gel-immersion EHL during dSOC for bile duct stones.

Fig. 1 Photographs showing an experimental comparison of blood being injected in the presence of: a saline; b the gelatinous liquid, with the visibility better with the gel than with saline.

An 82-year-old man was admitted to our hospital for treatment of huge common bile duct (CBD) stones. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted. Biliary cannulation using a standard ERCP catheter (MTW; Endoskopie, Wesel, Germany) was performed successfully. After contrast medium had been injected into the biliary tract, a 0.025-inch guidewire (VisiGlide 1; Olympus Medical Systems) was deployed, and endoscopic sphincterotomy was performed.

Subsequently, a digital single-operator cholangioscope (SpyGlass DS; Boston Scientific) was inserted into the CBD, and a CBD stone was successfully observed, while we repeatedly injected saline and performed aspiration. We performed EHL using a 2.4-Fr EHL probe combined with an electrohydraulic shockwave generator (Lithotron EL27; Walz Elektronik) ([Fig. 2 a]; [Video 1]). Although EHL of the stone was partially successful, bleeding occurred owing to injury to the bile duct wall, and the endoscopic view gradually became obscured ([Fig. 2 b]). The gelatinous liquid was therefore injected into the CBD, after which a clear endoscopic view was obtained ([Fig. 2 c]). In addition, hemostasis was spontaneously obtained. Finally, complete EHL was successfully performed and a stent was inserted ([Fig. 2 d]).

Fig. 2 Cholangioscopic views showing: a endoscopic electrohydraulic lithotripsy being performed; b poor visibility because of bleeding; c the distal flange of a lumen-apposing metal stent clearly seen following the injection of the gelatinous liquid; d successful deployment of the lumen-apposing metal stent.

Video 1 Gel-immersion electrohydraulic lithotripsy during digital single-operator cholangioscopy is performed to treat a large common bile duct stone after bleeding from a bile duct wall injury impaired the endoscopic view.

In conclusion, gel-immersion EHL during dSOC may be useful where there is an unclear endoscopic view because of bleeding.

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Competing Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ogura T, Imanishi M, Kurisu Y. et al. Prospective evaluation of digital single-operator cholangioscope for diagnostic and therapeutic procedures (with videos). Dig Endosc 2017; 29: 782-789
• 2 Troncone E, Mossa M, De Vico P. et al. Difficult biliary stones: a comprehensive review of new and old lithotripsy techniques. Medicina (Kaunas) 2022; 58: 120
• 3 Yano T, Takezawa T, Hashimoto K. et al. Gel immersion endoscopy: Innovation in securing the visual field - Clinical experience with 265 consecutive procedures. Endosc Int Open 2021; 9: E1123-E1127
• 4 Yano T, Nemoto D, Ono K. et al. Gel immersion endoscopy: a novel method to secure the visual field during endoscopy in bleeding patients (with videos). Gastrointest Endosc 2016; 83: 809-811
• 5 Yano T, Ohata A, Hiraki Y. et al. Development of a gel dedicated to gel immersion endoscopy. Endosc Int Open 2021; 9: E918-E924

Publication History

Article published online:
10 October 2022