Introduction: We present the case of a 60-year-old female who underwent percutaneous endoscopic laser lithotripsy using thulium laser technology for removal of multiple complex biliary stones. Initial symptoms began six months prior, warranting workup for choledocholithiasis and pancreatitis. Multiple ERCP and ERCP/percutaneous rendezvous procedures were attempted, but unsuccessful due to massive stone size and burden. The patient was left with an IR-placed 20-French Bentec tube serving as a biliary drain. The next month, she presented to our institution for return of abdominal symptoms and rapidly developed septic shock. Following recovery, the patient underwent laparoscopic converted to open pancreatic debridement and cholecystectomy with removal of large common bile duct calculi. She subsequently developed failure to thrive and poor nutritional status requiring TPN feeding post-operatively. The accompanying video case report aims to describe the definitive management of complicated biliary stones with the use of the thulium laser.
Methods: Percutaneous access to the biliary tree was co-managed by interventional radiology and re-dilated prior to endoscopy with an Amplatz dilating sheath to 24-French. Upon placement of a flexible cystoscope into the biliary tract, several stones were identified. The 200- and 365-micron Soltive Thulium laser fibers were utilized at a frequency of 50Hz with a pulse energy of either 0.2 or 0.4J (power 10W and 20W, respectively) to fragment stones. Extraction of fragments through the transhepatic sheath was facilitated with the use a 1.7-French 8mm N-gage Cook Nitonol basket or pushed forward through the ampulla with the endoscope and gentle sterile saline irrigant. Exit endoscopy was performed without presence of any residual calculi.
Results: Two-week follow-up cholangiogram demonstrated moderate common bile duct narrowing with rapid flow of contrast into the duodenum and without the previous obstruction. The percutaneous drain was then removed. Compositional stone analysis was significant for cholesterol (90%) and calcium bilirubinate (10%). Microbiology demonstrated growth of Seratia marcescens with fluoroquinolone, ceftriaxone and penicillin-class resistance and Enterococcus sensitive to vancomycin and ampicillin.
Conclusions: As described in our case and video, the use of thulium laser fiber was effective and safe in the removal of complex biliary stones refractory to alternative management options. This outcome is consistent with technical benefits seen in the setting of nephrolithiasis.
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