Successful endoscopic lithotripsy using a new digital cholangioscope through an overtube placed by an enteroscope

A 29-year-old woman who had undergone extrahepatic bile duct resection and hepaticojejunostomy for congenital biliary dilation was admitted to our hospital with cholangitis. Magnetic resonance cholangiopancreatography revealed multiple large intrahepatic bile duct stones ([Fig. 1]). Most of the stones were fragmented and removed by extracorporeal shock wave lithotripsy and endoscopic mechanical lithotripsy (LithoCrush V; Olympus, Tokyo, Japan) during double-balloon endoscope-assisted endoscopic retrograde cholangiopancreatography (EI-580BT; Fujifilm, Tokyo, Japan). However, intrahepatic stones in the right posterior branch could not be removed owing to the acute angle of the duct ([Fig. 2]). To perform intraductal lithotripsy under direct visualization, the enteroscope was withdrawn while leaving the overtube in situ. The direct cholangioscope (SpyGlass DS Direct Visualization System; Boston Scientific Japan, Tokyo, Japan) was successfully advanced through the overtube into the right posterior branch. The intrahepatic stones were visualized ([Fig. 3]) and successfully fragmented by electrohydraulic lithotripsy using the Autolith EHL system and 1.9-Fr probe (Boston Scientific Japan). Finally, the cholangioscope was exchanged for the enteroscope, and fragmented stones were extracted using a balloon catheter ([Fig. 4], [Video 1]).