Intrahepatic bile duct stone treatment combining electrohydraulic lithotripsy and peroral cholangioscopy through a choledochoduodenal fistula

A 62-year-old woman with intrahepatic bile duct stones ([Fig. 1]) and cholangitis symptoms was admitted to the hospital. She had undergone cholecystectomy 12 years previously for cholelithiasis. We performed endoscopic retrograde cholangiopancreatography (ERCP) to relieve her symptoms and reduce inflammation. Duodenoscopy showed an approximately 2-mm fistula in the duodenal bulb; guidewire placement and radiography confirmed a choledochoduodenal fistula. We performed balloon dilation of the choledochoduodenal fistula using a 6-mm balloon catheter (REN; Kaneka Medical Products, Tokyo, Japan). A single-operator fiberoptic cholangioscope direct visualization device (SpyGlass DS; Boston Scientific Corporation, Marlborough, Massachusetts, USA) was inserted over the guidewire into the intrahepatic bile duct under radiographic guidance, and all intrahepatic bile duct stones and debris were crushed via electrohydraulic lithotripsy (EHL). Finally, a 7-Fr plastic stent was inserted into the choledochoduodenal fistula ([Fig. 2] and [Fig. 3]; [Video 1]). Postoperative recovery was quick.