Direct Peroral Cholangioscopy in the Management of Refractory Stone Disease
Comments: Direct, peroral cholangioscopy in the management of refractory stone disease, presented by Gregory Cote, Steven Edmundowicz, Sreenivasa Jonnalagadda and Riad Azar. Cholangioscopy allows direct visualization of the bile duct; this has been used to distinguish malignant from benign bile duct lesions, as wall as in the management of complicated choledocholithiasis by allowing direct visualization for electrohydraulic lithotripsy, or EHL.
Traditional mother-daughter systems are limited by the need for two experienced endoscipists, poor visualization and the absence of a meaningful working channel. Single operator, fiberoptic cholangioscopy allows for four-way deflection and continuous irrigation, but the optical resolution remains inferior to standard endoscopic images. Direct, peroral cholangioscopy involves intubation of the biliary orifice using standard endoscopes. Wire guided cannulation has been described using and ultraslim 5.9 mm upper endoscope. Our group has recently reported a similar technique using a retrieval balloon to pull a standard gastroscope into the common hepatic duct.
We will present two cases where direct peroral cholangioscopy facilitated management of complicated bile duct stones. The first patient is a 50 year old woman who initially presented with acute onset of right quadrant abdominal pain and jaundice. MRCP demonstrated a large stone occluding the common hepatic duct. On initial ERCP, attempts to extract the stone sing retrieval balloons and a lithotripsy basket were unsuccessful. To distinguish an obstruction common hepatic duct stone from Mirizzi syndrome, she returned for cholangioscopy and probable EHL.
A guidewire is left in the proximal hepatic duct. An 8.8 mm gastroscope, preloaded with a retrieval balloon, is then advanced over the guidewire to the level of major papilla. The balloon, shown under fluoroscopy, was inflated above the stone and used to stabilize the position of the gastroscope, allowing it to be reduced into the common bile duct. This generates a remarkably high resolution image the depicting the stone obstructing the cystic duct orifice and causing extrinsic compression on the common hepatic duct consistent with Mirizzi syndrome. As a result of the scope's tenuous position once the balloon was withdrawn, EHL could not be performed through the gastroscope. Single operator, fiberoptic cholangioscopy was used to direct EHL. Note the inferior image quality of the fiberoptic cholangioscope compared to the initial high resolution picture. EHL fragmented the obstructing stone, permitting balloon extraction in a piecemeal fashion. After two sessions of EHL, there was no evidence if biliary obstruction. In summary, direct peroral Cholangioscopy clarified the diagnosis of Mirizzi syndrome prior to successful treatment using EHL through fiberoptic Cholangioscopy.
Our second example is an 84 year old woman who presented with recurrent epigastric pain and jaundice at a nearby hospital. ERCP demonstrated multiple filling defects in the common bile duct, but attempts at stone extraction using retrieval balloons and baskets were unsuccessful. Repeat ERCP at our institution demonstrated multiple filling defects. Mechanical lithotripsy was performed on two occasions, but the largest stone persisted. She returned for cholangioscopy with the intention of performing EHL.
In this case, the 8.8mm gastroscope directly visualized a distal filling defect through a widely patent biliary orifice. To facilitate direct cholangioscopy, balloon sphincteroplasty using an 18mm balloon is used to dilate the biliary orifice. This permits direct cannulation of the bile duct with the gastroscope. Once oriented, a long and flat stone is clearly visualized extending from the common hepatic duct to the lever of the bifurcation. Initial attempts to remove the stone using a large retrieval balloon are unsuccessful, flipping the stone from its original orientation. Since no retrieval baskets were available that fit through the working channel of the gastroscope, a retrieval net is carefully opened above the stone. The net is used to grasp the stone under direct visualization. The gastroscope is removed from the patient, bringing the 22 mm stone intact.
The gastroscope is advanced to the duodenum, where the biliary orifice is easily cannulated a second time. Fluoroscopy demonstrates the movement of the gastroscope as it is reduced to first examine the base of the cystic duct before advancing into the proximal common hepatic duct. Multiple 5 to 10mm stones persist, so the net is again used to retrieve several of these stones at a time. Several of these are released in the stomach, however, the larger stone material is trapped within the net, mandating the removal through the oropharynx.
This process is repeated until a total of eight stones, each measuring at least 5mm, are extracted. Clearance of stones is confirmed on balloon occlusion cholangiogram and sweep using an oversized retrieval balloon.
To our knowledge, this is the first reported example of a retrieval net being used for stone extraction under direct visualization using peroral cholangioscopy.
Limitations of this technique must be considered, particularly the difficulty in maintaining a stable scope position to allow for further diagnostic ant therapeutic intervention. Further, direct cannulation of the bile duct often requires a markedly dilated common duct and balloon sphincteroplasty. Use of an overtube with a smaller diameter endoscope may address these issues.
Thank you to the ASGE video editing scholarship program.
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Gregory A. Cote, MD, MS University of Washington |
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Citation: Cote, MS, GA (Jun 01 2009). Direct Peroral Cholangioscopy in the Management of Refractory Stone Disease. The DAVE Project. Retrieved Sep, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=865 Times viewed since Feb 2006: 3451 |
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