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Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa
Journal Pre-proof Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa Vincent Zimmer PII:
S0016-5107(20)30009-2
DOI:
https://doi.org/10.1016/j.gie.2020.01.002
Reference:
YMGE 11912
To appear in:
Gastrointestinal Endoscopy
Received Date: 23 July 2019 Accepted Date: 2 January 2020
Please cite this article as: Zimmer V, Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/j.gie.2020.01.002. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa Vincent Zimmer1,2
Affiliations: 1 2
Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany Department of Medicine II, Saarland University Medical Center, Saarland University,
Homburg, Germany
Correspondence to: Dr. Vincent Zimmer Department of Medicine Marienhausklinik St. Josef Kohlhof Klinikweg 1-5 66539 Neunkirchen Germany [email protected] phone: 0049-6821-3632070 fax: 0049-6821-3632624
Electronic word count: 200 Number of figures: 4 Manuscript Category: At the Focal Point Potential Conflict of Interest: Nothing to declare Keywords: bile duct stone, endoscopic retrograde cholangiopancreatography, bile duct trauma, lithotripsy
An 88-year-old female patient with putride cholangitis underwent emergent ERCP including maximum-incision sphincterotomy and temporary stent insertion. Because cholangiography indicated a giant stone >22 mm in a common bile duct (CBD) dilated up to 25 mm, we scheduled direct cholangioscopy (DC)-guided electrohydraulic lithotripsy (EHL) 5 days later after cholangitis resolution. Freehand-intubated DC using an ultra-slim upper endoscope provided adequate visualization the large CBD stone (A). After ample saline solution irrigation as medium for shock wave application, the procedure was started using the Autolith Touch unit with low-power, 5 pulses/activation as settings, occasionally producing clouds of biliary sludge (B, C). At later stages, when larger, rather mobile EHL fragments were targeted, settings were adapted to high-power and 3 shots with continuous irrigation sustained, until only small EHL fragments easily to be extracted were left over. Only thereafter did a circumscript thermal injury lesion of the biliary mucosa come to our attention, most likely representing inadvertent EHL-related ductal trauma, which remained without clinical sequelae (D). During the procedure itself, no apparent loss of visual control was noted; however, unnoticeable off-target shock wave transmission, visually obscured by underwater spark ignition, when treating mobile EHL fragments near the bile duct wall, may not be excluded.
S0016-5107(20)30009-2
DOI:
https://doi.org/10.1016/j.gie.2020.01.002
Reference:
YMGE 11912
To appear in:
Gastrointestinal Endoscopy
Received Date: 23 July 2019 Accepted Date: 2 January 2020
Please cite this article as: Zimmer V, Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa, Gastrointestinal Endoscopy (2020), doi: https://doi.org/10.1016/j.gie.2020.01.002. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Copyright © 2020 by the American Society for Gastrointestinal Endoscopy
Electrohydraulic lithotripsy-related thermal injury lesion of the biliary mucosa Vincent Zimmer1,2
Affiliations: 1 2
Department of Medicine, Marienhausklinik St. Josef Kohlhof, Neunkirchen, Germany Department of Medicine II, Saarland University Medical Center, Saarland University,
Homburg, Germany
Correspondence to: Dr. Vincent Zimmer Department of Medicine Marienhausklinik St. Josef Kohlhof Klinikweg 1-5 66539 Neunkirchen Germany [email protected] phone: 0049-6821-3632070 fax: 0049-6821-3632624
Electronic word count: 200 Number of figures: 4 Manuscript Category: At the Focal Point Potential Conflict of Interest: Nothing to declare Keywords: bile duct stone, endoscopic retrograde cholangiopancreatography, bile duct trauma, lithotripsy
An 88-year-old female patient with putride cholangitis underwent emergent ERCP including maximum-incision sphincterotomy and temporary stent insertion. Because cholangiography indicated a giant stone >22 mm in a common bile duct (CBD) dilated up to 25 mm, we scheduled direct cholangioscopy (DC)-guided electrohydraulic lithotripsy (EHL) 5 days later after cholangitis resolution. Freehand-intubated DC using an ultra-slim upper endoscope provided adequate visualization the large CBD stone (A). After ample saline solution irrigation as medium for shock wave application, the procedure was started using the Autolith Touch unit with low-power, 5 pulses/activation as settings, occasionally producing clouds of biliary sludge (B, C). At later stages, when larger, rather mobile EHL fragments were targeted, settings were adapted to high-power and 3 shots with continuous irrigation sustained, until only small EHL fragments easily to be extracted were left over. Only thereafter did a circumscript thermal injury lesion of the biliary mucosa come to our attention, most likely representing inadvertent EHL-related ductal trauma, which remained without clinical sequelae (D). During the procedure itself, no apparent loss of visual control was noted; however, unnoticeable off-target shock wave transmission, visually obscured by underwater spark ignition, when treating mobile EHL fragments near the bile duct wall, may not be excluded.