Fragmenting and Removing a Complex Biliary Stone under Direct Visualization

 

Patient History

A 70-year-old-man with a history of DM, HTN and HLP experienced elevated LFT’s (cholestatic pattern). A CT showed possible liver mets and dilated bile ducts. The patient then presented to an outside hospital with jaundice, RUQ pain and fever, which was found to have a choledocho-enteric fistula and a choledocho-colonic fistula for which he underwent open cholecystectomy, partial right hepatectomy, primary repair of the common bile duct, common duct exploration, lymphadenectomy and right transverse colon resection.

The patient underwent an ERCP, biliary sphincterotomy, and stone removal. At the time of surgery, cholangiograms were taken, which were read as normal. He continued to experience fever, weight loss and malaise, as well as persistent hyperbilirubinemia, elevated LFT’s and moderate RUQ pain. The patient was then referred to our hospital.

 

Procedure

Stone Fragmentation using EHL

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Initial Post-Cholecystectomy ERCP

An ERCP was then performed, at which time the patient had evidence of an incomplete sphincterotomy. In addition, a jagged 15mm stone was identified and large amounts of purulent bile extruded. Due to these observations, cholangioscopy was not performed and a 10Fr stent was placed. The patient’s symptoms resolved completely and he returned for definitive ERCP two months later.

 

Procedure

Stone Removal using SpyGlass™ Retrieval Basket

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Outcome & Discussion

Since undergoing the ERCP procedure with cholangioscopy and EHL, the patient has been asymptomatic. All LFT’s have resolved and he has regained the weight.