Endoscopic retrograde cholangiopancreatography (ERCP)-guided extraction is the gold
standard for biliary stone management. However, cystic duct confluence (CDC) stones
pose significant challenges due to their unique anatomical and stone characteristics,
with a lack of consensus on the optimal therapeutic approach [1]
[2]. The issue is further compounded in cystic-dilated CDC spaces, in which stones are
prone to escaping the retrieval catheter. Cholangioscopy-assisted lithotripsy is a
promising technique that facilitates complex stone management through direct visual
stone fragmentation [3]. Featuring a helical 8-wire design with a narrower interwire space at its tip and
rotational capability, the novel basket (RASEN2; KANEKA Medix, Tokyo, Japan) has shown
superior stone clearance versus conventional baskets in an experimental ex vivo setting
[4]. We describe an integrated approach using cholangioscopy-assisted lithotripsy and
RASEN2 for CDC stone removal.
A 31-year-old man was diagnosed at a prior hospital with recurrent cholecystitis and
cholangitis due to a large stone impacted at the CDC ([Fig. 1]). Initial attempts of ERCP-guided extraction were thwarted by the stone’s impaction
and anatomical complexity, rendering mechanical lithotripsy ineffective. Temporary
biliary stenting and sphincterotomy were performed. The extensive adhesions accompanied
by persistent peri-gallbladder inflammation made surgical intervention infeasible.
We performed cholangioscopy-assisted lithotripsy following patient referral to our
institution ([Fig. 2], [Video 1]).
Fig. 1 Computed tomography images. a,b A large stone (arrowheads) was impacted at the cystic duct confluence, leading to
cholestasis in both the bile duct and cystic duct.
Fig. 2 Cholangioscopy-assisted lithotripsy procedure. a Cholangiography revealed a significant obstruction at the cystic duct confluence
(CDC) caused by a large stone. The dilation around the CDC stone formed a pocket that
complicated extraction. b Cholangioscopy showed the CDC stone fully occupying the ductal lumen. c Electrohydraulic lithotripsy performed under saline irrigation successfully fragmented
the CDC stone. d the RASEN2 basket (KANEKA Medix, Tokyo, Japan), featuring a novel helical 8-wire
design with a smaller interwire space at the proximal tip and rotation function, was
employed for the stone extraction. e The rotation and enhanced expansion ability of RASEN2 enabled effective stone extraction
from the dilated CDC, ensuring secure contact with the duct wall and complete stone
capture. f The stones in the cystic duct could also be removed by RASEN2. g Post-extraction cholangiography showed the absence of residual stones at the CDC.
h Cholangioscopic assessment confirmed the complete clearance of stones from both the
bile duct and cystic duct. Arrowheads indicate the junction point of the cystic duct.
Synergistic application of cholangioscopy-assisted lithotripsy and the RASEN2 basket
(KANEKA Medix, Tokyo, Japan) was an effective therapeutic approach for cystic duct
confluence stones.Video 1
Under cholangioscopy visualization (SpyGlass DS; Boston Scientific, Marlborough, Massachusetts,
USA), a large CDC stone occupying the lumen was identified and then successfully fragmented
using electrohydraulic lithotripsy. Attempts to capture the fragmented stone with
conventional retrieval basket and balloon catheters failed due to the enlarged CDC.
However, switching to the RASEN2 basket facilitated fragment removal by navigating
the complexities of the dilated lumen, which ultimately led to complete stone clearance
as confirmed by cholangioscopic and cholangiographic assessments. Post-procedure,
the patient experienced no recurrences of cholecystitis or cholangitis.
The synergistic application of cholangioscopy-assisted lithotripsy and RASEN2 appears
to be an effective approach for challenging CDC stones.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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