1Sherif Hegab, 1Khaled Elrefaey, 1Islam Korayem, 1Shady Hegab
1Alexandria University Hospitals, Alexandria, Egypt
A 45 years old male patient presented with obstructive jaundice due to stricture at choledocho-jejunostomy anastomosis. He had past history of cholecystectomy with injury to the CBD followed by bilio-enteric anastomosis. MRCP revealed tight stricture at the surgical anastomosis together with multiple intrahepatic stones , about six stones, measuring from 10 to15 mm diameter seen in the left, right and common hepatic ducts. ERCP is un-accessible and surgical interference is contraindicated due to multiple co-morbidities.
Percutaneous cannulation of the left and right biliary radicles was performed and trial of balloon fragmentation of the biliary stones failed. Biliary external internal drainage catheters were inserted by passing the stricture for two months.
Revision of the patient condition with urologist having experience in uretroscope and Holium Laser lithotripsy was done and another session was scheduled.
The drainage catheters were removed and replaced by wide sheath10F allowing balloon dilatation 10mm wide and insertion of the uretroscpe 9F with laser fibers. We used 200Um laser fiber with 0.8 J/pulse of potency and 10 Hz of frequency . Fragmentation of all stones were performed under endoscopic vision performed through bilateral accesses followed by saline wash of the fragments aided by partially inflated balloon down to the jejunum. Small drainage catheters were left for continuous wash and follow up.
The patient was kept for 24 hours under observation in the hospital, then discharged in good condition without any complication.
Follow up MRCP after 48 hours revealed complete disappearance of the intrahepatic stones, apart from two tiny fragments less than 4 mm diameter which will be followed to assess their wash down.
Laser lithotripsy combined with endourologic endoscopy can effectively fragment intrahepatic biliary stones without any significant comorbidity..