Efficacy of Laser Lithotripsy with DBE-ERCP and Peroral Cholangioscopy in a Surgically Altered Anatomy for Intrahepatic Bile Duct Stones

A 34-year-old man underwent hepaticojejunostomy for congenital bile duct dilation at the age of 12. He often developed cholangitis due to intrahepatic bile duct stones (IHBDs), and conservative treatment with antibiotics was administered each time.

He visited our hospital for endoscopic treatment, and we used a double-balloon enteroscopy-assisted (DBE)-endoscopic retrograde cholangiopancreatography to remove the IHBDs, but the stones were too large to be effectively crushed or removed ([Fig. 1]). Therefore, we decided to perform holmium: yttrium-aluminum-garnet (Ho: YAG, Litho EVO, Edap TMS, Tokyo, Japan) laser lithotripsy for IHBDs with a POCS (Spyglass DS; Boston Scientific, Tokyo, Japan). However, the POCS could not pass through the DBE (EI-580BT; FUJIFILM, Tokyo, Japan) because the diameter of the POCS (3.5 mm) exceeded the working channel diameter of the DBE (3.2 mm). Therefore, we attempted direct POCS through the overtube after removing the DBE ([Figs. 2] and [3]). Laser lithotripsy with direct POCS was performed successfully ([Fig. 4A], [Video 1]). Finally, the crushed IHBDs were removed using a basket (Spy basket; Boston Scientific, Tokyo, Japan) and balloon catheter (Multi 3V plus; OLYMPUS, Tokyo, Japan) ([Fig. 4B]). After several sessions of laser lithotripsy, the IHBDs were almost completely removed, and he no longer developed cholangitis.

Fig. 1 Computed tomography (CT) revealed large intrahepatic bile duct stones (IHBDs).

Fig. 2 After the overtube was advanced to the anastomosis and the double-balloon enteroscopy (DBE) was withdrawn, while keeping the overtube in place.

Fig. 3 The intrahepatic bile duct stones (IHBDs) were confirmed by POCS.

Fig. 4 (A) Laser lithotripsy was performed successfully with the POCS. (B) The crushed intrahepatic bile duct stones (IHBDs) were removed using a basket catheter.

Video 1 Laser lithotripsy with direct peroral cholangioscope through the overtube placed by double-balloon endoscopy was effective for treating difficult intrahepatic bile duct stones in a patient with surgically altered anatomy.

Laser lithotripsy with direct POCS through the overtube placed by DBE was effective for difficult IHBDs in a patient with surgically altered anatomy (SAA).

Practical implications for endoscopists:

• Endoscopic treatment is less invasive than percutaneous treatment in patients with SAA and IHBDs.[1]

• Laser lithotripsy (LL) can be performed by withdrawing the DBE while leaving the overtube in place.[2] [3]

• By attaching the balloon at the tip of the endoscope with thread instead of a rubber band, the endoscope can be withdrawn from the overtube more easily ([Fig. 5]).

Fig. 5 Attaching the tip of the balloon to the endoscope with thread instead of a rubber band.

Conflict of Interest

None declared.

• References

• 1 Nakai Y, Kogure H, Yamada A, Isayama H, Koike K. Endoscopic management of bile duct stones in patients with surgically altered anatomy. Dig Endosc 2018; 30 (Suppl. 01) 67-74
• 2 Miwa H, Sugimori K, Maeda S. Laser lithotripsy with balloon enteroscopy-assisted peroral cholangioscopy for a large common bile duct stone after Billroth II gastrectomy. Dig Endosc 2024; 36 (09) 1059-1061
• 3 Tonozuka R, Itoi T, Sofuni A. et al. Novel peroral direct digital cholangioscopy-assisted lithotripsy using a monorail technique through the overtube in patients with surgically altered anatomy (with video). Dig Endosc 2019; 31 (02) 203-208

Publication History

Article published online:
11 June 2025