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Direct cholangioscopy using a standard-size gastroscope to guide mechanical lithotripsy after failed ERCP-based basket capture
Colangioscopia directa utilizando un gastroscopio de tamaño estándar para guiar la litotricia mecánica tras el fracaso de la captura de cestas basada en la CPRE
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Note also contrast media mostly flowing into the cystic duct (CD) reflective of the sub-occlusive nature of this “<span class="elsevierStyleItalic">giant</span>” stone. (<span class="elsevierStyleBold">B</span>) Direct cholangioscopy (DC) using a standard gastroscope likewise exposes the lumen-occlusive stone, and (<span class="elsevierStyleBold">C</span>) co-ordinated movements under endoscopic and fluoroscopic control resulted in successful basket capture (35-mm rotable device with high expansion forces). (<span class="elsevierStyleBold">D</span>) This was followed by an uncomplicated mechanical lithotripsy (ML) using an emergency lithotriptor device. 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Note also contrast media mostly flowing into the cystic duct (CD) reflective of the sub-occlusive nature of this “<span class="elsevierStyleItalic">giant</span>” stone. (<span class="elsevierStyleBold">B</span>) Direct cholangioscopy (DC) using a standard gastroscope likewise exposes the lumen-occlusive stone, and (<span class="elsevierStyleBold">C</span>) co-ordinated movements under endoscopic and fluoroscopic control resulted in successful basket capture (35-mm rotable device with high expansion forces). (<span class="elsevierStyleBold">D</span>) This was followed by an uncomplicated mechanical lithotripsy (ML) using an emergency lithotriptor device. (<span class="elsevierStyleBold">E</span>) After conventional ERCP-based extraction of ML fragments repeat DC up to the hilum firmly excluded remnant stone material in the diffusely dilated biliary system.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">An 85-year-old female underwent urgent endoscopic retrograde cholangiopancreatography (ERCP) under piperacillin/tazobactam due to acute bacterial cholangitis. Biliary access was achieved after transpancreatic sphincterotomy and prophylactic 5-Fr pancreatic single pigtail stenting. On (limited) cholangiogram an estimated 30-mm common bile duct (CBD) stone at the branch-off of a low-inserting cystic duct (CD) come to our notion. (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A) Biliary 10-Fr plastic stenting was performed after standard-incision papillotomy to ensure biliary drainage, and repeat ERCP was scheduled with intention to perform endoscopic papillary large-balloon dilation (EPLBD) to assist in stone extraction. This was accomplished up to 15<span class="elsevierStyleHsp" style=""></span>mm using a controlled radial expansion balloon without difficulties taking care to limit introduction of the device into the CBD, so as to avoid inflation alongside the large stone and diverticulum formation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> However, since the stone was not to be mobilized by a large-size ERCP balloon nor be captured in a <span class="elsevierStyleItalic">Dormia</span> basket, we performed freehand-intubated direct cholangioscopy (DC) using a standard size gastroscope (outer diameter 9.8<span class="elsevierStyleHsp" style=""></span>mm; working channel 2.8<span class="elsevierStyleHsp" style=""></span>mm) to fully visualize the nearly lumen-occluding giant stone. (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B) Basket capture under coordinated endoscopic and fluoroscopic guidance (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C) finally succeeded using a rotable basket with high expansion forces (twist’n’CATCH, Medwork, Höchstadt/Aich, Germany), and mechanical lithotripsy (ML) was performed without complications using an emergency lithotriptor device. (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>D) Following this, additional ML fragments were retrieved from the biliary system by standard ERCP technology. A final repeat DC up to the hilum firmly excluded remant stone disease in the diffusely dilated biliary system with ample pneumobilia after large-bore EPLBD further reducing the informativeness of pure cholangiography.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">DC-guided ML has rarely been reported, mostly because cholangioscopy-based stone management is dominated by electrohydraulic (EHL) and/or laser lithotripsy (LL) techniques considered more elegant and powerful in such setting.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> Notwithstanding, in this unique case catheter-based lithotripsy had not been planned beforehand. To conclude, cholangioscopy-guided ML using standard size upper endoscopes with a working channel with adequate diameter to accommodate ERCP equipment may represent another viable option, when ERCP-based <span class="elsevierStyleItalic">Dormia</span> basket capture as a <span class="elsevierStyleItalic">sine qua non</span> for ML fails.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Potential conflict of interest</span><p id="par0015" class="elsevierStylePara elsevierViewall">Nothing to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Potential conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1436 "Ancho" => 2007 "Tamanyo" => 295372 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(<span class="elsevierStyleBold">A</span>) An estimated 30-mm large distal common bile duct (CBD) stone – note limited cholangiogram due to acute cholangitis. Note also contrast media mostly flowing into the cystic duct (CD) reflective of the sub-occlusive nature of this “<span class="elsevierStyleItalic">giant</span>” stone. (<span class="elsevierStyleBold">B</span>) Direct cholangioscopy (DC) using a standard gastroscope likewise exposes the lumen-occlusive stone, and (<span class="elsevierStyleBold">C</span>) co-ordinated movements under endoscopic and fluoroscopic control resulted in successful basket capture (35-mm rotable device with high expansion forces). (<span class="elsevierStyleBold">D</span>) This was followed by an uncomplicated mechanical lithotripsy (ML) using an emergency lithotriptor device. (<span class="elsevierStyleBold">E</span>) After conventional ERCP-based extraction of ML fragments repeat DC up to the hilum firmly excluded remnant stone material in the diffusely dilated biliary system.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International consensus guidelines for endoscopic papillary large-balloon dilation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "T.H. Kim" 1 => "J.H. Kim" 2 => "D.W. Seo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gie.2015.06.016" "Revista" => array:6 [ "tituloSerie" => "Gastrointest Endosc." "fecha" => "2016" "volumen" => "83" "paginaInicial" => "37" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26232360" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Direct peroral cholangioscopy in the management of difficult biliary stones: a new tool to confirm common bile duct clearance. Results of a preliminary study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Anderloni" 1 => "F. Auriemma" 2 => "A. Fugazza" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.15403/jgld.2014.1121.281.bil" "Revista" => array:6 [ "tituloSerie" => "J Gastrointestin Liver Dis." "fecha" => "2019" "volumen" => "28" "paginaInicial" => "89" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30851177" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A “tandem approach” using sequential diagnostic (ultraslim) and therapeutic (standard size) direct freehand cholangioscopy to guide mechanical lithotripsy of a giant cystic duct remnant stone" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "V. Zimmer" 1 => "F. Lammert" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0043-106892" "Revista" => array:6 [ "tituloSerie" => "Endoscopy." "fecha" => "2017" "volumen" => "49" "paginaInicial" => "E160" "paginaFinal" => "E162" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28464207" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105705/0000004500000007/v1_202207130605/S0210570521001126/v1_202207130605/en/main.assets" "Apartado" => array:4 [ "identificador" => "93594" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Imágenes del mes" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/02105705/0000004500000007/v1_202207130605/S0210570521001126/v1_202207130605/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570521001126?idApp=UINPBA00004N" ]
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