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

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.