VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Endoscopic holmium laser lithotripsy to extract a large gallstone impacted in the terminal ileum
Figure 1. A, CT image showing calcified focus consistent with gallstone. B, Impacted gallstone in terminal ileum. C, Holmium laser lithotripsy used to fragment the stone. D, Basket extraction of fragmented stone.
The patient was a 72-year-old woman who presented with abdominal pain and nausea/vomiting. CT revealed a calcified focus in the terminal ileum with proximal bowel dilatation, reflecting a partial obstruction (Fig. 1A). With worsening symptoms and poor surgical candidacy, endoscopic therapy was attempted. Endoscopy revealed a strictured ileocecal valve secondary to chronic inflammation from an impacted gallstone (Fig. 1B). This was treated with balloon dilation, which allowed passage to the distal ileum, where a 3.5-cm gallstone was found. Attempts were made to fragment the stone by the use of electrohydraulic lithotripsy and a mechanical www.giejournal.org
lithotripter; however, both techniques were unsuccessful, and the stone’s hard consistency caused the mechanical lithotripter to break. Then, after holmium laser therapy was performed for a total of 3 hours, consisting of 14,422 pulses, 1,540.60 joules, and a total exposure time of 3600 seconds (Fig. 1C), the stone was successfully fragmented into multiple small fragments. These were removed with a combination of extraction baskets and balloons (Fig. 1D) (Video 1, available online at www.giejournal.org). In this case, endoscopic therapy with holmium laser lithotripsy was effective in treating a large gallstone impacted in the terminal ileum. Although not used here, combination Volume
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No.
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: 2014 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
techniques such as balloon dilation within a lithotripsymediated fragmented stone may increase the procedure’s efficiency and further reduce its time. This case shows that endoscopy can be an option for treating migrated gallstones, thereby avoiding surgery in high-risk patients. DISCLOSURE The following author disclosed financial relationships relevant to this publication: N. Gupta has received a
2 GASTROINTESTINAL ENDOSCOPY Volume
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No.
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: 2014
research grant from Cook Medical and has an ownership interest in Nuvilex, Inc. All other authors disclosed no financial relationships relevant to this publication. A. Samad Soudagar, MD, Jack Leya, MD, Neil Gupta, MD, MPH, Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, Illinois, USA
http://dx.doi.org/10.1016/j.gie.2014.01.039
www.giejournal.org
Endoscopic holmium laser lithotripsy to extract a large gallstone impacted in the terminal ileum
Figure 1. A, CT image showing calcified focus consistent with gallstone. B, Impacted gallstone in terminal ileum. C, Holmium laser lithotripsy used to fragment the stone. D, Basket extraction of fragmented stone.
The patient was a 72-year-old woman who presented with abdominal pain and nausea/vomiting. CT revealed a calcified focus in the terminal ileum with proximal bowel dilatation, reflecting a partial obstruction (Fig. 1A). With worsening symptoms and poor surgical candidacy, endoscopic therapy was attempted. Endoscopy revealed a strictured ileocecal valve secondary to chronic inflammation from an impacted gallstone (Fig. 1B). This was treated with balloon dilation, which allowed passage to the distal ileum, where a 3.5-cm gallstone was found. Attempts were made to fragment the stone by the use of electrohydraulic lithotripsy and a mechanical www.giejournal.org
lithotripter; however, both techniques were unsuccessful, and the stone’s hard consistency caused the mechanical lithotripter to break. Then, after holmium laser therapy was performed for a total of 3 hours, consisting of 14,422 pulses, 1,540.60 joules, and a total exposure time of 3600 seconds (Fig. 1C), the stone was successfully fragmented into multiple small fragments. These were removed with a combination of extraction baskets and balloons (Fig. 1D) (Video 1, available online at www.giejournal.org). In this case, endoscopic therapy with holmium laser lithotripsy was effective in treating a large gallstone impacted in the terminal ileum. Although not used here, combination Volume
-,
No.
-
: 2014 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
techniques such as balloon dilation within a lithotripsymediated fragmented stone may increase the procedure’s efficiency and further reduce its time. This case shows that endoscopy can be an option for treating migrated gallstones, thereby avoiding surgery in high-risk patients. DISCLOSURE The following author disclosed financial relationships relevant to this publication: N. Gupta has received a
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
research grant from Cook Medical and has an ownership interest in Nuvilex, Inc. All other authors disclosed no financial relationships relevant to this publication. A. Samad Soudagar, MD, Jack Leya, MD, Neil Gupta, MD, MPH, Division of Gastroenterology and Nutrition, Loyola University Medical Center, Maywood, Illinois, USA
http://dx.doi.org/10.1016/j.gie.2014.01.039
www.giejournal.org
