A stent-stone complex is a rare complication of long-term placement of biliary plastic stents [1]
[2]. Stones form around the proximal end of the stent, making endoscopic removal of the stent difficult. Herein we report a case of successful endoscopic removal of a stent-stone complex using peroral cholangioscopy-guided electrohydraulic lithotripsy (EHL).
An 80-year-old woman was referred to our hospital for treatment of large bile duct stones (35 mm) ([Fig. 1]). Peroral cholangioscopy-guided EHL was performed; however, stones could not be completely removed, and a plastic stent was placed ([Fig. 2]). Two months after peroral cholangioscopy-guided EHL, a 30-mm stent-stone complex formed ([Fig. 3 a]). We attempted to remove the stent-stone complex with grasping forceps; however, it could not be moved, and the plastic stent broke off at the grasping site ([Fig. 3 b]). We performed EHL again under peroral cholangioscopy (SpyScope DS II; Boston Scientific, Tokyo, Japan) for stent-stone complex extraction ([Video 1]). A stent-stone complex resembling a lollipop was observed in the distal bile duct ([Fig. 3 c]). The stone was fixed by the stent; this allowed the shock waves to be applied efficiently. The time taken to crush the stones around the plastic stent was approximately 10 min. The stones were then removed using a balloon catheter ([Fig. 3 d]). Balloon cholangiography after stone evacuation confirmed complete removal of the stones ([Fig. 3 e]). The patient recovered without cholangitis or bile duct stone recurrence.
Fig. 1 Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) images before the procedures. a Coronal view on CT showed a large stone in the common bile duct. b MRCP showed a defect suggestive of a 32-mm stone at the junction of the cystic duct and the common bile duct.
Fig. 2 The first electrohydraulic lithotripsy (EHL) under endoscopic retrograde cholangiopancreatography (ERCP). a ERCP showed a huge translucent filling defect in the common bile duct. b, c The presence of a yellow stone was confirmed by cholangioscopy and EHL was performed. d After EHL, the stones were removed with a balloon catheter; however, it was difficult to remove them completely.
Fig. 3 The second electrohydraulic lithotripsy (EHL) under endoscopic retrograde cholangiopancreatography (ERCP) for removal of the stent-stone complex. a The stent-stone complex was formed. b The stent was broken off during removal. c EHL was performed for stent-stone complex removal. d The stones were crushed for only approximately 10 minutes. e The stones were removed with a balloon catheter, and cholangiography confirmed that there were no residual stones.
Video 1 The procedure of electrohydraulic lithotripsy using peroral cholangioscopy for removal of a stent-stone complex.
Qualität:
Endoscopic removal of a stent-stone complex is difficult, and forcible extraction of a large stent-stone complex can cause papillary injury or biliary perforation. Further, surgery for a stent-stone complex [3]
[4] is highly invasive. In this case, EHL under peroral cholangioscopy efficiently crushed the stent-stone complex because the plastic stent served as an anchor. We believe that peroral cholangioscopy-guided EHL is an extremely useful method for stent-stone complex removal.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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