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Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones using laser lithotripsy and a disposable cholangioscope.
; however, there are limited data on their efficacy in complex therapeutic procedures. Here, we present a case of difficult bile duct stones in an elderly patient who was successfully treated by laser lithotripsy using a disposable duodenoscpe and cholangioscope.
A 98-year-old man presented with symptoms of jaundice and abdominal pain of 1-week duration. Imaging showed multiple filling defects in the common bile duct with prominent dilatation of the intrahepatic biliary radicals.
Advancing age has been considered a risk factor for post-ERCP cholangitis
; hence, we planned to use the novel single-use duodenoscope to limit the chances of ERCP-related infections. The Novel EXALT Model D (Boston Scientific, Marlborough, Mass, USA) was used for the procedure (Figure 1). It is lightweight and made of recyclable plastic, with a 4.2-mm working channel and a 1240-mm working length (video 1 available online at www.giejournal.org).
Figure 1Novel single-use (EXALT Model D, Boston Scientific Corp) duodenoscope.
In the index patient, after introduction of a novel single-use duodenoscope, selective common biliary duct (CBD) cannulation was performed, and a guidewire (0.025-inch, Visiglide Guidewire, Olympus Corp, Tokyo, Japan) was passed into the common bile duct. A cholangiogram (Figure 2) was consistent with earlier imaging; biliary sphinterotomy was performed using a Clevercut3V spinterotome (Olympus Corp). Balloon sphinteroplasty (up to 12 mm) was performed using a controlled radial expansion balloon dilator (Boston Scientific Corp). Later, a balloon sweep was performed using a stone extractor balloon, and multiple calculi were extracted. However, 1 large stone was still seen on subsequent cholangiogram.
Figure 2Initial cholangiogram showing multiple common biliary duct calculi.
Cholangioscopy with targeted laser lithotripsy was planned. After introduction of the single-use, single-operator cholangioscope (SpyScope DS, Boston Scientific Corp; Figure 3), the stone was identified in the proximal common bile duct (Figure 4). A LightTrail laser fiber (Boston Scientific Corp) was used to effectively pulverize the large CBD calculi. A balloon sweep was performed to extract the well-fragmented large calculus. Clearance of the CBD was confirmed with the use of balloon occlusion cholangiogram (Figure 5). In view of cholelithiasis, a 7F, 7-cm double-pigtail plastic stent (Zimmon, Cook medical LLC, Bloomington, IN, USA) was placed. The patient was comfortable after the procedure, and his laboratory results were normal 1 week after the procedure.
Figure 3Image showing disposable single-operator cholangioscope (SpyScope DS, Boston Scientific Corp) attached to single-use duodenoscope.
The elevator section of a conventional duodenoscope is difficult to reprocess because of its complex structure, including a recessed space containing an elevator, its cable, and its channel. This leads to the formation of biofilms, leading to increased post-ERCP infections.
A major concern with disposable duodenoscopes is the need to be able to effectively recycle the endoscope to avoid an environmental impact. This report, to our knowledge, demonstrates for the first time the therapeutic benefits of single-use duodenoscopes in performing complex procedures including cholangioscopy-guided laser lithotripsy. The single-use duodenoscope holds promise in reducing postprocedural infection without compromising the therapeutic capabilities of the duodenoscope.
Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones using laser lithotripsy and a disposable cholangioscope.
References
Rauwers A.W.
Voor A.F.
Buijs J.G.
et al.
High prevalence rate of digestive tract bacteria in duodenoscopes: a nationwide study.
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