Sa1285 SPYGLASS©-GUIDED ELECTROHYDRAULIC LITHOTRIPSY FOR INTRAHEPATIC AND DIFFICULT COMMON BILE DUCT STONES. A TWO-YEAR EXPERIENCE IN A SINGLE SURGICAL TERTIARY CENTER

Hepatolithiasis (HL) and difficult common bile duct (CBD) stones represent a challenging condition when associated with anatomic variations due to previous surgical procedures. Several endoscopic therapeutic approaches have been proposed. A combined radiologic-endoscopic technique using electrohydraulic or laser lithotripsy under percutaneous transhepatic cholangiography (PTC) has been also described. The aim of our study is to evaluate the efficacy and safety of Spyglass©-guided electrohydraulic lithotripsy (SpEHL) for HL and difficult CBD stones. From September 2014 to September 2016 data from 40 patients undergoing to Spyglass©-guided EHL (Walz EL©) for intrahepatic and/or difficult CBD stones were collected. All patients underwent a magnetic resonance cholangiopancreatography (MRCP) or abdominal ultrasound (Tsunoda classification was used). ERCP was the first line treatment for difficult CBD stones and/or HL. Peroral SpEHL was performed in case of ERCP failure (stone diameter >20mm, strictures). PTC was performed in case of intrahepatic (Tsunoda class III/IV) or impacted stones associated with narrowed CBD. In these cases percutaneous transhepatic cholangioscopy (PTCS) and SpEHL was performed. Patients with anatomic modifications due to previous surgery with a bilio-enteric anastomosis had a direct PTC approach with SpEHL. In cases of biliary anastomosis after liver transplantation a PTC approach was performed only after ERCP and SpEHL failure. The average follow-up period was 14 months. Complete stone clearance was achieved in 39/40 patients after a maximum of 3 consecutive procedures. 15 patients presented only difficult CBD stones (3 with Billroth type II gastrectomy), 5 with intrahepatic and CBD stones and 20 patients with only HL (10 with bilio-enteric anastomosis, 8 with biliary anastomosis due to liver transplantation and 2 with history of primary sclerosing cholangitis). Intrahepatic or CBD strictures were observed in 14 patients and biopsies made with Spybite© biopsy forceps (histological report: 12 benign and 2 malign). 1 patient underwent surgery (left hepatectomy with no histological evidence of oncological disease) after 3 procedure failures caused by a non-dilatable left lobe biliary duct stricture. Major adverse events were: 1 (2.5%) case of massive bleeding with the need of embolization and 4 (10%) cases of acute cholangitis treated with medical therapy. Recurrence of stones was observed in 5 cases (10%, 2 patients with liver transplantation and 3 patients with primary sclerosing cholangitis) successfully retreated. Peroral SpEHL is a safe and effective treatment in patients who have failed standard ERCP stone removal techniques. PTCS SpEHL seems to be very effective in patients with previous biliary tract surgical procedures with low complication and low stones’ recurrence rate.