Intrahepatic Cholangiolithiasis Extraction During Endoscopic Retrograde Cholangiopancreatography Using a Disposable Ultrafine Peroral Cholangioscope

Summary

Here, we present a novel disposable ultrafine peroral cholangioscopy for intrahepatic choledochal stone extraction under direct visualization during endoscopic retrograde cholangiopancreatography (ERCP), demonstrating satisfactory results of minimally invasive treatment for patients suffering from this disease.

Abstract

Hepatolithiasis refers to the presence of stones in the branching bile ducts above the confluence of the left and right hepatic ducts, often accompanied by extrahepatic bile duct stones. These stones can induce local infections and secondary bile duct strictures, making their discharge difficult and leading to severe complications. While endoscopic retrograde cholangiopancreatography (ERCP) is an effective minimally invasive method for treating cholangiolithiasis, it is often challenging to address hepatolithiasis using this technique.

This article presents a step-by-step description of an ERCP procedure using a novel disposable ultrafine peroral cholangioscope. In this case, stones were successfully removed from a patient with intrahepatic cholangiolithiasis under direct visualization using the novel disposable ultrafine peroral cholangioscope. The therapeutic process highlighted the immediacy and efficiency of the peroral cholangioscopy in navigating intrahepatic bile ducts and extracting stones. This approach offers valuable insights for managing similar cases in the future, potentially benefiting more patients with comparable conditions.

Introduction

Hepatolithiasis refers to stones located in the bile ducts branching above the confluence of the right and left hepatic ducts. These stones can cause bile duct obstruction, leading to impaired bile drainage and symptoms such as abdominal pain, fever, and jaundice (yellowing of the skin and sclera). Chronic hepatolithiasis may result in serious complications, including biliary cirrhosis, hepatic atrophy, and other liver lesions. Currently, the primary treatment for hepatolithiasis involves surgical interventions such as choledochotomy, hepatectomy, and laparoscopic choledochotomy. However, these procedures are associated with significant trauma and prolonged recovery p....

Protocol

This study was approved by the ethics committees of Shanghai Tong Ren Hospital and Shanghai Jiao Tong University School of Medicine. (Ethics Approval No: A2023-085-01).

1. Preoperative preparation

1. Conduct preoperative imaging to evaluate the location, size, and number of intrahepatic bile duct stones.
2. Assess the patient's eligibility for the endoscopic operation and identify any contraindications.
3. Administer prophylactic rectal indomethacin (100 mg) 30 min prior to ERCP to mitigate post-ERCP pancreatitis (PEP) risk, per current guidelines⁶. Provide intravenous hydr....

Results

In July this year, a 37-year-old female patient who presented with upper abdominal pain with fever was diagnosed as cholangitis and intrahepatic choledocholithiasis. Similar symptoms a year ago, improved with anti-infective treatment. Computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP) indicated cholangitis and intrahepatic choledocholithiasis (Figure 1). The patient's preoperative biochemical and coagulation indexes had no obvious abnormalities, without underlyin.......

Discussion

With the continuous development of medicine and the deepening of research into pathogenesis, we can utilize increasingly minimally invasive methods to treat a variety of diseases, such as ERCP for cholelithiasis. Conventional ERCP is performed with the assistance of x-ray imaging, and the inability to perform real-time cholangioendoscopic diagnosis and treatment is its shortcoming. In contrast, traditional choledochotomy can ensure the removal of stones under direct vision, but it is more invasive⁷

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Choledochoscope Extraction Basket	Micro-Tech (Nanjing) Co.Ltd	CEB00000	Mesh basket for stone removal
CleverCut 3V	Olympus Medical	KD-V411M-0725	selective biliary cannulation and papillary sphincterotomy
Duodenoscopy	Olympus Medical	TJF-260V	Endoscopy for ERCP
EyeMAX	Micro-Tech (Nanjing) Co.Ltd	CDS22001	Disposable ultrafine peroral cholangioscope
Fusion Extraction Balloon With Multiple Sizing	Cook Medical	G31537	Balloon for clearing bile duct stones
Fusion Titan Biliary Dilation Balloon	Cook Medical	FS-BDB-6X4	Dilatation of the primary papilla
Jagwire High Performance Guidewire	Boston Scientific	M00556580	Guidewire
Nasal Biliary Drainage Sets	Cook Medical	ENBD-7-LIGUORY	Nasobiliary drainage