Cases and Techniques Library (CTL) E519 Electrohydraulic lithotripsy of large bile duct stones under direct cholangioscopy with a double-balloon endoscope Fig. 2 a Direct cholangioscopy with a double-balloon endoscope reveals large bile duct stones in the right hepatic duct. b Successful fragmentation of the bile duct stones with electrohydraulic lithotripsy. an 18-mm filling defect in the right hepat- Video 1 ic duct (●" Fig. 1,●" Fig.2a). Fig. 1 Cholangiography with a short double- After attempts to extract the bile duct balloon endoscope delineates large bile duct stones with a retrieval balloon and basket stones (arrow) in the right hepatic duct of an catheters had failed, EHL was performed 82-year-old woman with a history of hepatico- with the AUTOLITH System and a 1.9-Fr, jejunostomy. 250-cm-long probe (Northgate Technolo- gies, Elgin, Illinois, USA). The distal end of the double-balloon endoscope was insert- The use of a short double-balloon endo- ed into the bile duct, and water irrigation scope facilitates the endoscopic removal for EHL was achieved by pushing the bal- of bile duct stones in patients with surgi- loon against the anastomosis and flushing cally altered anatomy [1,2]. However, the saline through the channel. Large stones narrow and long working channel of the were successfully fragmented with EHL, Electrohydraulic lithotripsy combined with double-balloon endoscopy for large bile duct double-balloon endoscope occasionally followed by complete removal with a bal- stones in a patient with a history of hepaticoje- ●" ●" makes the procedure difficult and time- loon catheter ( Fig. 2b, Video1). No junostomy. consuming. Herein, we present the case procedure-related complications were of a patient with a history of hepaticojeju- observed. nostomy in whom large bile duct stones This is the first report of successful stone Ryunosuke Hakuta, Hirofumi Kogure, were successfully fragmented and re- fragmentation with EHL under direct Hiroyuki Isayama, Atsuo Yamada, moved under direct visualization with a visualization with a short double-balloon Tsuyoshi Hamada, Yousuke Nakai, short double-balloon endoscope and elec- enteroscope. The effectiveness of EHL Kazuhiko Koike trohydraulic lithotripsy (EHL). combined with a single-balloon endo- Department of Gastroenterology, An 82-year-old woman with a history of scope has been reported [3], and given the Graduate School of Medicine, hepaticojejunostomy and Roux-en-Y re- potential superiority of a double-balloon University of Tokyo, Tokyo, Japan construction for congenital biliary dila- enteroscope over a single-balloon entero- tation was admitted with cholangitis due scope in terms of endoscope insertion [4], to intrahepatic bile duct stones. Endo- EHL with a double-balloon enteroscope References scopic retrograde cholangiopancreatogra- can further increase the technical success 1 Aabakken L, Bretthauer M, Line PD. Double- balloon enteroscopy for endoscopic retro- phy (ERCP) was carried out with a short rate of stone removal in patients with sur- grade cholangiography in patients with a double-balloon endoscope (EC-450BI5, gically altered anatomy. Roux-en-Y anastomosis. Endoscopy 2007; 2.8-mm-wide and 152-cm-long working 39: 1068–1071 channel; Fujifilm Corp., Tokyo, Japan), Endoscopy_UCTN_Code_TTT_1AR_2AH 2 Tsujino T, Yamada A, Isayama H et al. Experi- and biliary access was readily obtained ences of biliary interventions using short double-balloon enteroscopy in patients with a usual ERCP cannula and a 0.025-in Competing interests: None with Roux-en-Y anastomosis or hepaticoje- guidewire. Cholangiography delineated junostomy. Dig Endosc 2010; 22: 211–216 Hakuta Ryunosuke et al. Endoscopic electrohydraulic lithotripsy of large bile duct stones… Endoscopy 2015; 47: E519–E520 E520 Cases and Techniques Library (CTL) 3 Kao KT, Batra B. Single-balloon-assisted Bibliography Corresponding author ERCP with electrohydraulic lithotripsy for DOI http://dx.doi.org/ Hiroyuki Isayama, MD, PhD the treatment of a bile duct stone in a pa- 10.1055/s-0034-1392669 Department of Gastroenterology tient with a hepaticojejunostomy. Gastro- Endoscopy 2015; 47: E519–E520 Graduate School of Medicine intest Endosc 2014; 80: 1173 © Georg Thieme Verlag KG University of Tokyo Takano N Yamada A Watabe H 4 , , et al. Single- Stuttgart · New York 7-3-1 Hongo Bunkyo-ku balloon versus double-balloon endoscopy ISSN 0013-726X Tokyo for achieving total enteroscopy: a random- Japan 113-8655 ized controlled trial. Gastrointest Endosc Fax: +81-3-3814-0021 2011; 73: 734–739 [email protected] Hakuta Ryunosuke et al. Endoscopic electrohydraulic lithotripsy of large bile duct stones… Endoscopy 2015; 47: E519–E520.