Occasionally, biliary stone management can be really challenging, depending on location,
size, number, altered anatomy, and presence of strictures [1]. Although different approaches can be used in this setting, such as endoscopic retrograde
cholangiopancreatography (ERCP), percutaneous transhepatic biliary drainage (PTBD),
and extracorporeal shock wave lithotripsy or surgery [2], more complex cases may require management using a combination of techniques [3]
[4]
[5].
A 40-year-old woman presented with recurrent cholangitis due to right hepatolithiasis
([Fig. 1]). Past history included a failed ERCP, and subsequent cholecystectomy with biliary
exploration at another hospital. First, left PTBD was performed to improve the patient’s
clinical status. A multidisciplinary team then decided in favor of surgical bile duct
exploration with hepaticojejunostomy; however, the right intrahepatic stone could
not be identified, even with intraoperative ultrasound. Biliary exploration through
the PTBD drain was scheduled for the postsurgical recovery period. Meanwhile, cholangitis
recurred, and the patient underwent urgent right PTBD following discovery of a 1.7 cm
biliary stone, which had impacted in the confluence of the right anterior and posterior
sectoral biliary ducts ([Fig. 2]). Balloon fragmentation was attempted, but was not successful. In addition, a basket
was not considered to be a safe method of retrieval because of the size of the stone.
Fig. 1 Intrahepatic stone (arrow) observed at magnetic resonance cholangiopancreatography.
Fig. 2 Impacted biliary stone in the right hepatic duct observed during percutaneous transhepatic
cholangiography.
After clinical recovery of the patient, the multidisciplinary team opted for a hybrid
procedure involving access to the biliary tree through the right PTBD site and cholangioscopy-guided
laser lithotripsy using the intraductal cholangioscopy system SpyGlass DS (Boston
Scientific, Marlborough, Massachusetts, USA). Informed consent was obtained.
The procedure was performed under general anesthesia, and prophylactic ciprofloxacin
400 mg was given intravenously. The previously inserted biliary drain was exchanged
for a 12 Fr sheath ([Fig. 3]), allowing the insertion of the Spyscope under fluoroscopic and direct visualization
([Fig. 4]). A large impacted stone causing biliary ulceration was visualized. Lithotripsy
was performed using Holmium laser with power output at 10 W ([Fig. 5], [Video 1]). Stone fragments were mobilized through the hepaticojejunostomy ([Fig. 6]), and new biliary drains were inserted bilaterally. The total procedure time was
58 minutes. The patient developed postoperative cholangitis, which was treated successfully
with antibiotics.
Fig. 3 Visualization of a 12 Fr sheath through the right percutaneous transhepatic biliary
drain insertion site.
Fig. 4 Insertion of the Spyscope (Boston Scientific, Marlborough, Massachusetts, USA) through
the percutaneous access.
Fig. 5 Cholangioscopy-guided laser lithotripsy.
Video 1 SpyGlass (Boston Scientific, Marlborough, Massachusetts, USA) percutaneous transhepatic
cholangioscopy-guided lithotripsy.
Fig. 6 A large stone fragment was mobilized through the hepaticojejunostomy.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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