Clin Endosc.  2021 Sep;54(5):660-668. 10.5946/ce.2020.256-IDEN.

Cracking Difficult Biliary Stones

• Angsuwatcharakon P
• Rerknimitr R

• KMID: 2520548
• DOI: http://doi.org/10.5946/ce.2020.256-IDEN

Abstract

Apart from difficult biliary cannulation, biliary stone removal is considered one of the hurdles in endoscopic retrograde cholangiopancreatography. Generally, simple common bile duct (CBD) stones can be removed either with an extraction balloon or a basket. However, there are difficult stones that cannot be removed using these standard methods. The most difficult stones are large CBD stones and impacted stones in a tapering CBD. A few decades ago, mechanical lithotripsy was usually required to manage these stones. At present, endoscopic papillary large balloon dilation (EPLBD) of the biliary orifice has become the gold standard for large CBD stones up to 1.5 cm. EPLBD can reduce the procedural time by shortening the stone removal process. It can also save the cost of the devices, especially multiple baskets, used in mechanical lithotripsy. Unfortunately, very large CBD stones, stones impacted in a tapering CBD, and some intrahepatic duct stones still require lithotripsy. Peroral cholangioscopy provides direct visualization of the stone, which helps the endoscopist perform a probe-based lithotripsy either with an electrohydraulic probe or a laser probe. This technique can facilitate the management of difficult CBD stones with a high success rate and save procedural time without significant technical complications.

Keyword

Electrohydraulic lithotripsy; Large bile duct stone; Laser lithotripsy; Mechanical lithotripsy; Per-oral cholangioscopy

Figure

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  Fig. 1. A large bile duct stone successfully treated with endoscopic papillary large balloon dilation (EPLBD). (A) Cholangiogram showing a large bile duct stone. (B) Endoscopic view of EPLBD after sphincterotomy. (C) A large stone removed with an extraction balloon. (D) Occlusion cholangiogram showing no residual filling defect.

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  Fig. 2. Mechanical lithotripsy for a difficult bile duct stone. (A) A 1-cm stone proximal to a considerably tapered bile duct. (B) Mechanical lithotripsy was successfully performed using a through-the-scope mechanical lithotripter, and stone clearance was achieved.

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  Fig. 3. Laser lithotripsy guided by single-operator cholangioscopy. (A) A disposable cholangioscope operated by a single endoscopist. The laser probe is inserted through the accessory channel of the cholangioscope, which is inserted through the accessory channel of the duodenoscope. (B) Cholangioscopic view of intraductal stone fragmentation with a laser probe.

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  Fig. 4. Prototype of a mutibending ultra-slim scope. (A) The distal end has two bending sections for facilitating biliary insertion. (B) Two accessory channels (2.2 and 1 mm) designed to facilitate irrigation during intraductal lithotripsy. (C) Free-hand bile duct insertion of the scope. (Picture courtesy of Prof. Jong H. Moon, MD, PhD, FASGE, FJGES, Director of Digestive Disease Center, SoonChunHyang University School of Medicine, Bucheon/Seoul, Korea).

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  Fig. 5. Recommendation for the management of difficult bile duct stones.

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