Post written by Jason Behary, MBBS, from the Department of Gastroenterology and Hepatology, St George Hospital and University of New South Wales, in Sydney, Australia.

Digital per-oral cholangioscopy performed under combined endoscopic and fluoroscopic control allows visualization and treatment of large and difficult to remove intra- and extrahepatic biliary calculi. A 200-micron holmium laser lithotripsy fiber is advanced down the 1.2mm channel of the cholangioscope. Laser power settings of 10 watts are safe and allow successful stone fragmentation. The first case demonstrates the effectiveness of this technique in the management of a large impacted common bile duct calculus. The safety of this technique is highlighted in case 2. Following an earlier iatrogenic duodenal perforation, treated with an over-the-scope clip device, cholangioscopic stone fragmentation with holmium laser lithotripsy is used to treat large biliary calculi without disturbing the site of the previous perforation.  The final case demonstrates how calculi within various intrahepatic biliary segments can be accessed and effectively treated under fluoroscopic and endoscopic control.

This case series demonstrates the efficacy and safety of digital per-oral cholangioscopy-guided holmium laser lithotripsy to manage complex biliary calculi. The technique allows for direct visualization and management of either large biliary calculi or those within peripheral intrahepatic segments that cannot be removed at conventional ERCP. Furthermore, the technique is relatively safe since the stones are accessed under direct vision and holmium laser lithotripsy appears less likely to cause biliary injury at the recommended power settings compared with electrohydraulic probes.

Digital per-oral cholangioscopy with holmium laser lithotripsy should be considered as a therapeutic option in patients with complex stone disease that cannot be removed at conventional ERCP.

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