Cholangioscopy-guided holmium laser lithotripsy of a stone trapped in a mechanical lithotripter

摘要

Large common bile duct (CBD) stones can be removedwith mechanical lithotripsy, although over-the-baskettechniques such as electrohydraulic or pulsed dye laser lithotripsy can be necessary in cases of stone impaction.1 Wereport the case of a 42-year-old woman with a 30-mm stonein the CBD in whom mechanical lithotripsy was attemptedafter wide sphincterotomy. However, during the procedure,a rupture occurred in the traction wire of the basket, next tothe handle. Emergency lithotripsy (EL) with use of anexternal-type system was immediately attempted, but wirefracture occurred again (2 times), turning its length shorterthan the metallic sheath of the EL and rendering EL impossible. Given that the stone and basket were impacted inthe CBD (Figs. 1 and 2), a temporary biliary stent wasinserted, and the metallic wires were oriented from themouth to the nose (Fig. 3). Five days later, holmium laserlithotripsy was performed under direct per-oral cholangioscopy by use of a gastroscope advanced into the CBD(free-hand technique). A gastroscope was used becauseaccess to the biliary tree was easy and because of its superiorimage quality and maneuverability. We used holmium lasertechnology (Auriga XL Ho:YAG; Lynton Surgical, Cheshire,U.K.) delivered through a 365-mm fiber, with energy levelsset between 800 and 1500 mJ at a frequency of 8 to 15 Hz(Fig. 4; Video 1, available online at www.VideoGIE.org). Agreen aiming beam was used to target the stone, andenergy was delivered under direct vision in bursts of lessthan 5 seconds under continuous saline solution infusion,to avoid damage to the CBD wall. The stone fragmentsand the trapped basket were then removed, and completeCBD clearance was achieved.