Suryaprakash Bhandari, MD, from the Baldota Institute of Digestive Sciences, Global Hospitals, in Mumbai, India, shares this VideoGIE case “Single-operator cholangioscopy-guided holmium laser lithotripsy: the new-age ‘rescue’ lithotripsy.”

A 40-year-old woman with a large bile duct (BD) stone was referred for ERCP. Cholangiography revealed a dilated BD with a single large stone within the relative narrowing of the lower BD. After we performed biliary sphincterotomy, we attempted mechanical lithotripsy with a trapezoid basket (Boston Scientific, Natick, USA).

However, despite repeated attempts, the stone could not be crushed with the lithotripter. In addition, the stone could not be disengaged from the basket. The handle of the basket was then cut at the junction with the sheath. The basket with the enclosed stone was now lying within the duct and the endoscope was withdrawn with the wire hanging out through the mouth. Soehendra “rescue” lithotripsy could not be attempted because the wires of the trapezoid basket are not very sturdy and hence there was a very high possibility of fracture of the wires midway during lithotripsy. A single operator cholangioscope (Boston Scientific, USA) was passed by the side of the wire in the bile duct, and holmium laser lithotripsy was done. Good stone fragmentation was achieved. The trapezoid basket could now be extracted. The bile duct was swept with the balloon, and the duct was cleared of all stone fragments.

Our case highlights successful case management of an impacted stone within a lithotripsy compatible basket. Failure of mechanical lithotripsy is not a common occurrence. As claimed by the manufacturer if the basket fails to crush a hard bile duct stone, the wire may get fractured at the tip and on table emergency can be tide over by placing a temporary bile duct stent. However, in our case in spite of repeated attempts, the stone could not be crushed nor could be disengaged from the basket. Unfortunately the basket also did not get fractured at the tip.

Hence on table rescue options with us were:

• Attempt Soehendra “rescue “lithotripsy.
• To subject the patient directly for surgery.
• To subject the patient for ESWL followed by ERCP.
• Re-attempt mechanical lithotripsy using a larger Olympus BML 3Q basket
• Do large balloon sphincteroplasty of the lower bile duct and papilla by the side of the basket wires and re-attempt stone extraction.
• Use single operator cholangioscopy guided holmium laser lithotripsy.

Of all the above options, we choose cholangioscopy-guided laser lithotripsy in view of its minimal invasiveness, easy availability at our center, and our previous large experience with this technology in patients with difficult bile duct stones. Also, successful single session ductal clearance with this technology is very high.

To date, there is no literature available to predict failure of mechanical lithotripsy as occurred in our case. Unlike renal stones, majority of bile duct stone are radiolucent in view of low calcium content and high cholesterol content. These stones are not very hard in consistency and hence mechanical lithotripsy has high success rates. However if it fails, we need to use variety of options as highlighted above depending upon the local availability of advanced lithotripsy options like ESWL, EHL, cholangioscopy and expertise too.

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