Endoscopic extraction of a giant common bile duct stone

The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%. The dimensions of a giant biliary calculus are equal to or bigger than 2cm. Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy. Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone. This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.

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Endoscopic extraction of a giant common bile duct stone

Authors

Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux

Abstract

The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.

Mots-clés

common bile duct stone, endoscopy, extraction, giant biliary calculus, ERCP, cholelithiasis

Type de vidéo

Vidéo chirurgicale

Durée

03'45''

Publication

2010-12

Popularité

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Sous-titres

E-publication

WeBSurg.com, Dec 2010;10(12).
URL: http://www.websurg.com/doi-vd01en3106.htm

Endoscopic extraction of a giant common bile duct stone

1. Clinical case presentation 00'10''

This is a case of 76-year-old woman referred to our endoscopic unit by the urologist. While being treated for renal cancer, elevated bilirubin, GGT and alkaline phosphatase were found during investigation. MRCP was performed and a giant CBD stone with associated gallbladder calculi were detected. She was scheduled for an endoscopic treatment for common bile duct lithiasis followed by nephrectomy and cholecystectomy at a later date.

2. Identification of duodenal diverticulum 00'43''

With the patient under general anesthesia and in supine position, ERCP was performed. The duodenum was reached and a diverticulum in the third portion was visualized. The second part of the duodenum was then reached and the ampulla of Vater was visualized without any difficulty.

3. Retrograd cholangiography and stone visualization 01'02''

On retrograde cholangiography, there was the big stone (of size approximately 2.5cm) in the common bile duct with a significant dilation of the extra-hepatic bile ducts and moderate dilation of the intra-hepatic biliary tree. The gallbladder was well opacified with its solitary stone.

4. Sphincterotomy 01'25''

We left a guide wire in the hepatic duct and a small sphincterotomy was carried out at eleven o\' clock using a Dreamtome RX 44 sphincterotome by Boston Scientific. An ERBE electric generator was used. It was set on AUTO CUT effect 2 mode. The short guide wire was then changed for a long one (450cm) and left in the hepatic duct.

5. Balloon dilatation 01'56''

Next, a 12-15mm-CRE balloon (Boston Scientific) was inserted symmetrically in the papilla and slowly inflated to 3, 4.5, 7mmHg to get the radial dilatation of 12, 13.5, 15mm. After the balloon was removed, we found out that the papilla opened up so as to permit the extraction of the stone. A small stone came out spontaneously.

6. Stone extraction 02'27''

With the guide wire always in place, a catheter-type Dormia basket retrieval system was inserted in the common bile duct and the big stone was extracted. Multiple passages in the CBD were performed and some sludge was removed. The stone removed was of size approximately two and a half centimetres in length and 1cm thick. The patient recovered well, without any pain and was started on full intake 6 hours later. The next day, the bilirubin, Gamma GT and alkaline phosphatase levels came down. There were no features suggestive of postoperative pancreatitis. Two days after the endoscopic stone extraction, the patient underwent nephrectomy and open cholecystectomy, and 6 days later she was discharged from the hospital. In conclusion, this combined technique (sphincterotomy and large balloon sphincteroplasty) can be safely utilized for endoscopic management of giant CBD calculi, but at the expert hands.