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Volume 5, Issue 11 , Pages 1333-1338, November 2007

Transpapillary Cholangioscopy–Directed Lithotripsy in Patients With Difficult Bile Duct Stones

Cyrus Piraka
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, Michigan
Raj J. Shah
- Division of Gastroenterology & Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
Nida S. Awadallah
- Division of Gastroenterology & Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
Daniel A. Langer
- Division of Gastroenterology & Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
Yang K. Chen
- Division of Gastroenterology & Hepatology, University of Colorado at Denver and Health Sciences Center, Denver, Colorado
- Address requests for reprints to: Yang K. Chen, MD, University of Colorado at Denver and Health Sciences Center, Division of Gastroenterology & Hepatology, Anschutz Outpatient Pavilion, MS F735, 1635 N Ursula St, Room OP6710, PO Box 6510, Aurora, Colorado 80045. fax: 720-848-2749.

published online 24 July 2007.

Background & Aims: There are limited prospective data and long-term follow-up on cholangioscopy-directed management of difficult bile duct stones. The study objectives were to evaluate the safety and efficacy of cholangioscopy-directed lithotripsy in patients who had failed standard endoscopic retrograde cholangiopancreatography (ERCP) techniques and to determine the stone recurrence rate. Methods: Consecutive patients with biliary stones referred for cholangioscopy after failure of conventional stone therapy were enrolled and followed prospectively. Results: Between February 2000–October 2004, 32 consecutive patients had cholangioscopy-directed lithotripsy (30 electrohydraulic lithotripsy, 2 mechanical) after a mean of 3.3 (range, 2–14) failed ERCPs. Stones were intrahepatic (N = 8); extrahepatic (N = 18); or both (N = 6). Biliary strictures were present in 20 (63%) patients. Cholangioscopy identified additional stones not seen at ERCP in 9 (28%) patients. A mean of 1.4 lithotripsy sessions achieved complete (N = 26, 81%), partial (N = 5, 16%), or failed (N = 1, 3%) stone clearance. Follow-up was available in 28 (88%) patients for a mean of 29.2 months (95% confidence interval, 20.3–38.1 months). Stone recurrence occurred in 4 of 22 (18%) patients with complete clearance and follow-up data; 3 had primary sclerosing cholangitis. There were 2 minor periprocedural complications and 1 late complication. Conclusions: Cholangioscopy-directed lithotripsy is a safe and effective treatment in patients who have failed standard ERCP stone removal techniques. Stone recurrence is low in patients who had complete stone clearance except in patients with primary sclerosing cholangitis. Cholangioscopy detects stones missed by cholangiography.

Abbreviations used in this paper: CP, cholangioscopy, EHL, electrohydraulic lithotripsy, ERCP, endoscopic retrograde cholangiopancreatography, ESWL, extracorporeal shock wave lithotripsy, PSC, primary sclerosing cholangitis