Syed Mujahid Hassan, FCPS and colleagues from the Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Civil Hospital Karachi, in Karachi, Pakistan present this video case “Successful removal of intrahepatic bile duct stones by using a combination of extracorporeal shock wave lithotripsy and direct peroral cholangioscopy.”

This video demonstrates the successful removal of intrahepatic bile duct stones using a combination of 2 novel techniques, that is, extra-corporeal shock wave lithotripsy and direct per-oral cholangioscopy (DPC).

A 50-year-old gentleman presented with multiple left intrahepatic duct (LIHD) and common bile duct (CBD) stones. At ERCP, cholangiography showed a 1 cm mobile stone in CBD and multiple stones in LIHD, largest measuring 1.5 cm. A generous papillotomy was performed and CBD stone was removed easily; however, LIHD stones could not be retrieved. A 7 Fr x 250 cm nasobiliary drain (NBD) was placed and then the patient was subjected to 5 sessions of extra corporeal shock wave lithotripsy (ESWL) with an interval of 24-48 hours. The highest energy level was 9 Kilojoules and the highest frequency was 1.5 Hz. The number of shocks per session ranged from 4,000 to 6,000. After satisfactory fragmentation of all the stones, the patient was subjected to follow up ERCP. Pre ERCP NBD cholangiogram confirmed satisfactory fragmentation of the stones (Figure 1). These stone fragments were cleared using dormia basket and extractor balloon, however many LIHD stone fragments could not be removed.

At this stage it was decided to perform DPC. After placement of an assembly of 0.035 inches guide wire and 5 Fr guiding catheter, the ERCP scope was removed and an ultra slim video gastroscope (USVG) was introduced over this assembly deep into LIHD. Only minimal air insufflations were required as the biliary system was already dilated. The fragments of stone from LIHD were grabbed in 8-wired dormia basket and then pulled down upto the level of CBD (Figure 2). They were not initially extracted into duodenum to avoid multiple re-entry of USVG into CBD as it was technically difficult. After removal of all the stone fragments from LIHD, USVG was withdrawn and all the CBD stone fragments were then retrieved by dormia basket and extractor balloon using ERCP scope. To document complete clearance of biliary system, USVG was again introduced by the same method. Post procedure course was uneventful and the patient has remained completely asymptomatic till the last follow up, 10 months post procedure.

Find the video online.

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