Cholangioscopic Laser Lithotripsy for Complete Encrustation of the Extra-hepatic Biliary Tree By 15-year Retained Biliary Stent

The authors report on a case of stone-stent complex encrusting the entire extra-hepatic biliary tree after biliary stent placed in 1993 for gallstone-associated pancreatitis. The patient presented with cholangitis 14 years after initial treatment, and underwent multiple serial ERCP procedures for biliary decompression and papillotomy, but failed removal of the stent-stone complex. Figure 1 shows MRCP image with complete encrustation of the extra-hepatic biliary tree. Initial treatment consisted of percutaneous biliary decompression with an internalized trans-hepatic drain. After 6-week maturation of the trans-hepatic drain tract, the patient was taken to the operating room for percutaneous cholangioscopic laser lithotripsy. A sheath was placed in the drain tract, enabling passage of a 7.5 French choledochoscope, and the Holmium laser was used with a 200 micron fiber at 1.0 Joules and 10 Hz. The encrusted stone was progressively fractured off the stent in two operative stages separated by two weeks, allowing endoscopic retrieval of the stent at the second stage. Two weeks following the stent retrieval, follow-up cholangiogram revealed complete clearance of the biliary tree (Figure 2).

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Program Number: P505

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