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 periods, posing challenges, particularly for physically weaker patients^1,2.

With the advancement of minimally invasive techniques, endoscopic retrograde cholangiopancreatography (ERCP) has proven effective for managing extrahepatic bile duct stones. It can also address some extrahepatic stones extending into the intrahepatic ducts or intrahepatic stones located near the hilum. During ERCP, stones are removed using an endoscope that is introduced through the mouth and navigates through the duodenal papilla into the bile ducts. This minimally invasive approach avoids traditional surgery, reduces patient suffering, and minimizes physical disruption. However, ERCP is not without challenges, particularly in achieving selective cannulation of the target intrahepatic bile ducts^3,4,5.

In this article, we present the case of a 37-year-old female patient with recurrent hepatolithiasis who underwent ERCP facilitated by a novel disposable ultrafine peroral cholangioscope. The goal of this protocol is to illustrate the technical approach, clinical safety, and outcomes of peroral cholangioscopy-assisted ERCP in the management of hepatolithiasis.

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 hydration and antibiotic prophylaxis.

2. Duodenoscopic exploration

1. Perform duodenoscopy under general anesthesia with the patient in the left prone position using CO₂ insufflation.
   1. Gently advance the duodenoscope through the esophagus into the stomach. Under lateral visualization, navigate the scope along the greater curvature toward the pylorus.
   2. Using subtle rotation and angulation, transverse the pylorus to enter the duodenal bulb. Achieve further advancement into the descending duodenum (second portion) by reducing loops via clockwise rotation and upward angulation.
   3. Confirmation of the major duodenal papilla's location is critical. Minimize air insufflation to optimize visualization and patient comfort.
2. Aspirate residual gastric fluid and locate the main duodenal papilla.
   NOTE: Ensure safe access to the descending duodenum and confirm adequate visualization of the papilla using the duodenoscope's lateral view and x-ray fluoroscopy.

3. Selective biliary intubation of the main papilla

1. Observe the morphology and opening of the main papilla to determine the course of the common bile duct.
2. After identifying the major duodenal papilla, position the duodenoscope to align the cannulation axis with the biliary orifice.
3. Gently advance a sphincterotome or catheter, often combined with a guidewire under fluoroscopic guidance. Make subtle adjustments in scope position (e.g., upward angulation, slight rotation) and catheter manipulation to achieve selective bile duct entry.
   NOTE: Retraction of bile or contrast injection confirms proper cannulation. If difficulty arises, techniques such as wire-guided access, precut sphincterotomy, or adjunctive devices (e.g., pancreatic stent placement) may be employed. Minimal trauma to the papilla and avoidance of pancreatic duct cannulation are prioritized to reduce pancreatitis risk.

4. Endoscopic retrograde cholangiography

1. After successful cannulation, perform gentle aspiration of bile through the catheter or sphincterotome under fluoroscopic guidance to confirm intraluminal positioning and exclude air. Subsequently, inject water-soluble iodinated contrast medium incrementally under real-time imaging to visualize biliary anatomy.
2. Inject the contrast medium slowly to visualize the bile ducts, identify filling defects, and assess the location, size, and number of stones.
   NOTE: Care is taken to avoid overfilling, which may obscure pathology or increase pancreatitis risk. Aspiration-injection cycles help optimize ductal opacification while minimizing pressure-related complications. Pancreatic duct cannulation is avoided unless clinically indicated.

5. Peroral cholangioscopy-assisted selective intrahepatic bile duct cannulation

1. Place the guidewire into the lumen of the peroral cholangioscopy to insert the peroral cholangioscopy along the guidewire through the endoscopic channel into the common bile duct.
2. Under x-ray fluoroscopy and with the guidewire, advance the peroral cholangioscopy to the target bile duct branches as identified on the cholangiogram.
   NOTE: Maintaining a stable position of the duodenoscope relative to the major duodenal papilla, real-time imaging guidance was used to ensure successful peroral cholangioscopy intrahepatic bile duct selective cannulation.

6. Direct peroral cholangioscope-guided stone extraction

1. Introduce the mesh basket through the peroral cholangioscopy, grasp the stone under direct visualization, and withdraw the cholangioscopy to the main papilla, releasing the stone into the duodenum.
2. Repeat this process until all intrahepatic bile duct stones are removed.
   NOTE: The procedure requires patience, care, and the help of a skilled assistant to ensure the guidewire remains in place and stone extraction is efficient.

7. Nasobiliary tube insertion

1. Confirm stone clearance with cholangiography, then place a nasobiliary tube along the guidewire into the target intrahepatic bile duct under x-ray fluoroscopy. This ensures bile duct patency and facilitates postoperative monitoring.
2. In the postoperative period, observe routine blood counts, liver function, blood amylase, and nasobiliary drainage.

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