Electrohydraulic lithotripsy with peroral choledochoscopy

Objective - To determine the efficacy of peroral electrohydraulic lithotripsy performed with an extra large duodenoscope (outside diameter 14.8 mm) and a choledochoscope with a diameter of 4.1 mm (Olympus 'mother and baby' endoscope system) in the removal of very large stones from the common bile duct. Design - Prospective study of patients with giant stones in the common bile duct that were resistant to extraction by conventional means. Setting - Endoscopy unit at a university hospital. Patients - Four women and one man aged 48-82 (mean 66.4 years) with a total of nine stones in their common bile ducts ranging from 2.2 to 3.6 cm in diameter. Interventions - Peroral electrohydraulic lithotripsy was performed after intravenous sedation and under antibiotic cover. Two endoscopists took part in each procedure, coordination being achieved by means of a video monitor. The procedures were performed with a Lithotron EL-23 lithotripter and a 3 French lithotripsy probe inserted through the choledochoscope under direct vision. Main outcome measure - Complete clearance of the common bile duct confirmed by occlusion cholangiography. Results - All nine stones (mean minimal diameter 2.6 cm; mean maximal diameter 3.1 cm) were successfully fragmented by electrohydraulic lithotripsy, allowing subsequent extraction with the aid of endoscopy and clearance of the common bile duct. A median of three (range two to five) sessions of endoscopic retrograde cholangiopancreatography were required to achieve complete clearance of the ducts. Patients stayed a median of eight days in hospital after lithotripsy (range eight to 14). There were no complications. Conclusion - Peroral electrohydraulic lithotripsy offers a safe and effective alternative for the management of patients with large stones in the common bile duct.