Digital cholangioscopy-guided electrohydraulic lithotripsy for intraepathic and difficult biliary stones with peroral and percutaneous approach. A three-year experience in a single surgical tertiary center

Background Hepatolithiasis (HL) and difficult common bile duct (CBD) stones represent a challenging condition when associated with anatomic variations due to previous surgical procedures. Several endoscopic therapeutic approaches have been proposed. A combined radiologic-endoscopic technique using electrohydraulic or laser lithotripsy under percutaneous transhepatic cholangiography (PTC) has been also described. The aim of our study is to evaluate the efficacy and safety of the SpyGlass™-guided electrohydraulic lithotripsy (SpEHL) for intrahepatic and difficult CBD stones using peroral and percutaneous approach. Materials and Methods From September 2014 to September 2017 data from symptomatic patients with intrahepatic and/or difficult CBD stones that underwent SpEHL were collected. All patients initially underwent an abdominal ultrasound exam and then magnetic resonance cholangiopancreatography (MRCP) and/or computed tomography (CT) to confirm the diagnosis, to detect the biliary stones and to evaluate anatomical abnormalities due to previous abdominal surgical operation. CT and/or MRCP results were classified according to the Tsunoda classification. ERCP was the first line treatment for difficult CBD stones and/or HL. Peroral SpEHL was performed in case of ERCP failure (stone diameter >25mm, strictures). PTC was performed in case of intrahepatic (Tsunoda class III/IV) or impacted stones associated with narrowed CBD. In these cases, percutaneous transhepatic cholangioscopy (PTCS) and SpEHL was performed. Patients with anatomic modifications due to previous surgery with a bilio-enteric anastomosis had a direct PTC approach with SpEHL. In cases of biliary anastomosis after liver transplantation a PTC approach was performed only after ERCP and SpEHL failure. The average follow-up period was 24±3.6 months. Results Complete stone clearance was achieved in 29/30 (96.6%) after a maximum of 3 consecutive procedures. 10 patients presented only difficult CBD stones (3 with Billroth type II gastrectomy), 5 with intrahepatic and CBD stones and 15 patients with only HL (9 with bilio-enteric anastomosis, 6 with biliary anastomosis due to liver transplantation). Intrahepatic or CBD strictures were observed in 12 patients and biopsies made with Spybite© biopsy forceps (histological report: 10 benign and 2 malign). 1 patient underwent surgery (left hepatectomy with no histological evidence of oncological disease) after 3 procedure failures caused by a non-dilatable left lobe biliary duct stricture. Major adverse events were: 1 (3.3%) case of massive bleeding with the need of embolization and 4 (13%) cases of mild cholangitis treated with medical therapy. Recurrence of stones was observed in 4 cases (13.7%) successfully retreated. Conclusion Peroral-SpEHL is an effective and safe rescue treatment in patients who have failed standard ERCP stone removal techniques. PTCS-SpEHL seems to be very effective in patients with altered anatomy, showing low complication and recurrence rates.