Usefulness of electrohydraulic lithotripsy gel-immersion cholangioscopy for giant common bile duct stones

Abstract

Figures

We observed common bile duct stones using a digital cholangioscope.

a When using saline solution, our visibility was impaired by fragments of scattered stones and debris. b Compared to the use of saline solution, we found it easier to see clearly when using the gelatinous liquid.

We slowly inject the gel into the forceps channel port using a 10 ml or 20 ml syringe, adding 1–2 ml at a time.

Full text

Electrohydraulic lithotripsy (EHL) is an effective treatment for large common bile duct (CBD) stones. However, endoscopic visualization can be impaired by turbid bile or stone fragments/debris generated during the procedure. Gel-immersion endoscopy using a transparent, viscous gel (Viscoclear; Otsuka Pharmaceutical Factory, Tokushima, Japan 1 ) has been reported as an effective method for securing the visual field 2 3 . We employed this technique to secure the cholangioscopic visual field during EHL.

A 74-year-old woman was admitted to our hospital for the treatment of a large CBD stone. EHL was performed after endoscopic retrograde cholangiopancreatography was attempted. A digital cholangioscope (SpyGlass DS; Boston Scientific, Marlborough, MA, USA) via a 0.025-inch guidewire was inserted into the CBD. A CBD stone (diameter: 20 mm) was successfully observed ( Fig. 1 ).

We observed common bile duct stones using a digital cholangioscope.

We performed EHL using an EHL probe combined with an electrohydraulic shockwave generator (Autolith Touch; Boston Scientific, Marlborough, MA, USA 4 ). The EHL generator was set to high power at a rate of 30 pulses/s. Although normal saline is generally used for CBD filling during EHL, it induces poor visual fields. To overcome this problem, ViscoClear was used ( Video 1 ).

Gel-immersion electrohydraulic lithotripsy was performed to treat a large common bile duct stone.Video 1

During EHL, the maintained visual field was clearer using Viscoclea than using saline irrigation, even in the presence of scattered stone fragments and debris ( Fig. 2 ). When visualization deteriorated during the procedure, injecting 1–2 mL of the gel restored the field of view ( Fig. 3 5 ). A total of 30 mL of gel was used for this procedure. The procedure was safely completed while maintaining a clear visual field. The stones were successfully fragmented using approximately 1,000 shockwaves under a clear visual field. In conclusion, this procedure effectively improves endoscopic visibility and may reduce the risk of increased bile duct pressure when a small amount of gel is used.

a When using saline solution, our visibility was impaired by fragments of scattered stones and debris. b Compared to the use of saline solution, we found it easier to see clearly when using the gelatinous liquid.

We slowly inject the gel into the forceps channel port using a 10 ml or 20 ml syringe, adding 1–2 ml at a time.

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