Value of direct peroral cholangioscopy combined with laser lithotripsy in treatment of patients with difficult common bile duct stones

Objective To investigate the clinical effect of direct peroral cholangioscopy combined with laser lithotripsy in the treatment of difficult bile duct stones. Methods A total of 21 patients with difficult bile duct stones who underwent cholecystolithotomy under endoscopic retrograde cholangiopancreatography in Lanzhou First People's Hospital from October 2014 to October 2017 were enrolled. All patients were treated with small endoscopic sphincterotomy, and balloons with a size of 10-15 mm were selected based on the maximum diameter ( or maximum diameter + 2 mm) of stones to perform balloon dilatation. The carunculae minor or the juxta-diverticulum papillae were cut open and then dilated, and those which could not be cut open were directly dilated with balloons. The criterion for papillary dilatation was that a 10 mm balloon could pass the papillary opening smoothly. The ultrafine endoscope was inserted into the common bile duct via the papillary opening, laser lithotripsy was conducted under the direct view, a specially designed basket was used to remove the stones, and the common bile duct was rinsed repeatedly. Results The ultrafine endoscope successfully entered the common bile duct and found the stones, with a success rate of 100%. Of all patients, 16 ( 66. 7%) underwent direct insertion, 5 ( 23. 8%) underwent insertion assisted by guide wire, and 2 ( 9. 5%) underwent insertion assisted by outer casing. The mean insertion time was 4. 9 ± 2. 9 minutes. The success rate of lithotripsy was 81. 0%, and 4 patients ( 19%) experienced failed lithotripsy. There were no serious complications or surgery-related deaths during the treatment. One patient ( 4. 8%) experienced fever, right upper abdominal pain and tenderness, and increases in leukocytes and procalcitonin after surgery and was improved after the treatment with antibiotics for biliary tract infection. One patient ( 4. 8%) experienced moderate postoperative pancreatitis and was improved after conservative treatment. Conclusion Direct peroral cholangioscopy is a safe and effective technique for the diagnosis and treatment of difficult common bile duct stones. In particular, its combination with laser lithotripsy shows great advantages.