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PERORAL CHOLANGIOSCOPY USING SPYGLASS DIRECT VISUALIZATION PROBE AND ELECTROHYDRAULIC LITHOTRIPSY FOR THE MANAGEMENT OF SYMPTOMATIC CHOLELITHIASIS IN A NON-SURGICAL CANDIDATE
ML Bechtold, WP Pais, P Tiwari, MR Antillon
Division of Gastroenterology, University of Missouri, Columbia, MO, USA
BACKGROUND: Laparoscopic cholecystectomy is the treatment of choice for symptomatic gallstones, but not for those who are poor surgical candidates. Mechanical lithotripsy using a lithotripser has also been utilized for choledocholithiasis. Cholangioscopy using an Olympus video-choledocoscope (baby scope) and directed electro-hydraulic lithotripsy (EHL) via lithotripser has been used for treating choledocholithiasis. However, this technique has not been reported for the treatment of symptomatic stones in the gallbladder. Our report describes the feasibility of directed-EHL by peroral cholecystoscopy using a SpyGlass direct visualization probe (M00546030) passed via SpyScope access and delivery catheter (M00546230) passed via side-viewing duodenoscope for treating symptomatic cholelithiasis in a non-surgical candidate.
Case report: 65 year old male with multiple medical comorbidities including ischemic cardiomyopathy (NYHA class IV) presented with cholangitis. Ultrasound revealed multiple gallstones in the common bile duct (CBD), cystic duct, and gallbladder. The patient was a poor surgical candidate based on cardiac status. He had undergone multiple attempts to remove the gallstones using endoscopic retrograde cholangiopancreatography (ERCP). Multiple stones were removed by various endoscopic techniques. A large gallbladder stone (4 cm) could not be removed despite mechanical lithotripsy. A SpyGlass direct visualization probe (M00546030) passed via SpyScope access and delivery catheter (M00546230) passed via a side-viewing duodenoscope successfully entered the gallbladder. A Soehendra 4-6 mm biliary dilator was used to gain access via the cystic duct. The large gallstone was recognized under direct visualization as well as fluoroscopy. EHL of this stone was successfully performed using the NORTHECH M9-200-00-Autolith EHL generator and NORTECH MICRO II lithotripter probe. Multiple stone fragments were flushed out. Subsequently, a 10-Fr double pigtail stent was placed into the gallbladder to ensure adequate drainage. There were no complications. After the procedure, the patient noticed symptomatic improvement. The patient was scheduled for a repeat SpyGlass cholangioscopy with repeat EHL as needed.
CONCLUSIONS: A SpyGlass direct visualization probe (M00546030) passed via SpyScope access and delivery catheter (M00546230) can be used for EHL of gallbladder stones that cannot be treated by traditional therapy.