Application of holmium laser in endoscopic retrograde cholangiopancreatographygall gallbladder-preserving cholecystolithotomy

We report a case of a 59-year-old woman diagnosed with cholecystolithiasis ([Fig. 1]). She frequently experienced discomfort in the right upper abdomen after consuming greasy foods but was reluctant to undergo cholecystectomy. Consequently, she sought our assistance and requested a gallbladder-preserving cholecystolithotomy. Following thorough communication, the decision was made to proceed with endoscopic retrograde cholangiopancreatography (ERCP)-based gallbladder-preserving cholecystolithotomy.

Fig. 1 Magnetic resonance imaging of the gallstone.

After placement of the pancreatic stent, biliary duct stent, and two fully covered metal stents (FCMSs) (one of which extended into the gallbladder cavity), a gallstone approximately 11 mm in diameter was observed when the choledochoscope entered into the gallbladder cavity. However, the gallstone was too large and hard to remove through the FCMS ([Fig. 2]), and it could not be fragmented by electrohydraulic lithotripsy. Consequently, holmium laser lithotripsy was used ([Fig. 3]). The gallstone was subsequently crushed and extracted by a reticular basket. Two days later, a choledochoscopy reticular basket was used to remove the remaining gallstone fragments from the gallbladder cavity. After that, the gallbladder was thoroughly rinsed. Finally, all the stents were removed, and a double-pigtail plastic stent was placed between the gallbladder and the duodenum for drainage ([Video 1]). There was no significant discomfort or complication after treatment, and the double-pigtail plastic stent was removed by gastroscope in the outpatient clinic 1 month later ([Fig. 4]). No recurrence was found during the 13-month follow-up.

Fig. 2 a The gallstone shown on X-ray. b The gallstone observed through choledochoscopy.

Fig. 3 Holmium laser lithotripsy under direct vision of the choledochoscope.

Fig. 4 The double-pigtail plastic stent was removed by gastroscope 1 month later.

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Application of a holmium laser in endoscopic retrograde cholangiopancreatography-based gallbladder-preserving cholecystolithotomy.Video 1

The gallbladder plays a crucial role in the digestive system, and complications such as abdominal pain and diarrhea may arise following cholecystectomy. ERCP-based gallbladder-preserving cholecystolithotomy can preserve the integrity and even functionality of the gallbladder after gallstone removal, making it a viable treatment option [1]. For large stones in the gallbladder, holmium laser lithotripsy under direct visualization with the choledochoscope is also an effective alternative.

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• Reference

• 1 Hao Y, Yang Z, Yang H. et al. Gallbladder-preserving cholecystolithotomy. Expert Rev Gastroenterol Hepatol 2022; 16: 265-272