Successful removal of an impacted stone in the common bile duct by electric lithotripsy using a needle-knife and a forward-viewing endoscope

Although stones in the common bile duct (CBD) can be endoscopically removed [1] [2], stone impaction in the CBD occasionally occurs as a severe complication [3] [4]. We encountered a case of stone impaction in the CBD after endoscopic papillary balloon dilation (EPBD), which could be successfully treated by electrically cutting the stone using a needle-knife.

A 68-year-old man visited our hospital because of acute cholangitis. Abdominal computed tomography revealed a calcified stone of 10 mm in diameter in the CBD ([Fig. 1]). After obtaining informed consent, we attempted endoscopic retrograde cholangiopancreatography (ERCP) using a duodenoscope (JF260V; Olympus, Tokyo, Japan), and diagnosed choledocholithiasis ([Fig. 1]).

Fig. 1 Bile duct stone on imaging studies. a, b Computed tomography images showing a bile duct stone of 10 mm in diameter. c Cholangiograph showing the stone in the bile duct.

We performed EPBD (QBD-8X3; Cook Medical, Inc., Bloomington, Indiana, USA) ([Fig. 2]). Although we attempted stone extraction using a basket catheter (Nitinol-lithotomy basket, 4 wires, 25 × 40 mm; MTW Endoskopie, Wesel, Germany), the stone was tightly impacted within the biliary orifice ([Fig. 3]). After cutting and removing the outer sheath of the impacted catheter, we exchanged the instrument to a forward-viewing endoscope (GIF-Q260; Olympus) with a hood (Elastic Touch, slit&hole, F-010; Top Corp., Tokyo, Japan) attached to its tip. After positioning the endoscope close to the impacted stone, we electrically cut the stone using a needle-knife (KD-1L-1; Olympus) (Forced Coagulation 50 W, ICC200; Erbe, Tübingen, Germany) under direct visualization, in a fashion similar to the technique of endoscopic submucosal dissection [5] until stone reduction was confirmed ([Fig. 4]; [Video 1]).

Fig. 2 Endoscopic papillary balloon dilation. a Endoscopic view. b Fluoroscopic view.

Fig. 3 Endoscopic view showing the impacted stone in the biliary orifice after endoscopic papillary balloon dilation.

Fig. 4 Endoscopic view: cutting and retrieval of the stone. a The stone was electrically cut using a needle-knife, in a fashion similar to the technique of endoscopic submucosal dissection. b The stone was gripped with grasping forceps after being electrically cut using the needle-knife.

Video 1: In the present case a bile duct stone was tightly impacted within the biliary orifice after endoscopic papillary balloon dilation. We electrically cut the stone using a needle-knife under direct visualization, in a fashion similar to the technique of endoscopic submucosal dissection, and then broke it with grasping forceps. An endoscopic view of electrical lithotripsy using a needle-knife is shown.

After breaking the stone with grasping forceps (FG-47L-1; Olympus) ([Fig. 4]; [Video 1]), we could easily extract the impacted stone by pulling the impacted wire through the duodenoscope, which had been inserted to the second part of the duodenum using the wire for guidance ([Fig. 5]). No adverse events occurred during or after the procedure.

Fig. 5 Retrieval of the stone. a Fluoroscopic view of a duodenoscope inserted into the second part of the duodenum using the impacted wire for guidance. b The impacted stone was successfully removed after being broken using the needle-knife and grasping forceps.

This technique has been suggested to be useful for the retrieval of impacted stones associated with ERCP. However, its reported use is limited to case reports; therefore, further evaluation should be performed in the future.

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• References

• 1 Classen M, Ossenberg FW. Non-surgical removal of common bile duct stones. Gut 1977; 18: 760-769
• 2 Shah SK, Mutignani M, Costamagna G. Therapeutic biliary endoscopy. Endoscopy 2002; 34: 43-53
• 3 van Dullemen H, Stuifbergen WNHM, Juttmann JR. et al. Simple release of an impacted Dormia basket during endoscopic bile duct stone extraction. Endoscopy 1993; 25: 374
• 4 Ryozawa S, Iwano H, Taba K. et al. Successful retrieval of an impacted mechanical lithotripsy basket: a case report. Digest Endosc 2010; 22: S111-S113
• 5 Gotoda T, Ho KY, Soetikno R. et al. Gastric ESD current status and future directions of devices and training. Gastrointest Endoscopy Clin N Am 2014; 24: 213-233