Peroral cholecystoscopy with electrohydraulic lithotripsy for treatment of symptomatic cholelithiasis in end-stage liver disease (with videos).

BACKGROUND Patients with end-stage liver disease have an increased risk of symptomatic gallstone disease, as well as complications associated with cholecystectomy. We hypothesized that peroral transpapillary cholecystoscopy with electrohydraulic lithotripsy of gallbladder stones is technically feasible and beneficial in patients who are high operative risks. DESIGN Observational, descriptive. PATIENTS Patients with Child's class C cirrhosis and with gallstone symptoms who were awaiting liver transplantation. INTERVENTIONS Gallbladder stenting, dilation of the cystic duct, cholecystoscopy, electrohydraulic lithotripsy, ursodiol therapy. MAIN OUTCOME MEASUREMENTS Gallbladder access and visualization, stone clearance, symptom relief, and complications. RESULTS The gallbladder wall and stones were adequately visualized. Electrohydraulic lithotripsy achieved stone clearance after two sessions. Mild postprocedure pancreatitis occurred after the first treatment. The patient remained symptom free, stent free, and stone free until a liver transplantation, which was performed 25 months later. LIMITATIONS Proof of concept performed in a single patient. CONCLUSIONS Peroral transpapillary cholecystoscopy is technically feasible. Electrohydraulic lithotripsy of gallbladder stones under direct vision can achieve stone clearance. Patients with cirrhosis who are awaiting transplantation and other high-risk surgical candidates with symptomatic gallstone disease may benefit from this treatment option. Studies to assess the efficacy and safety of this novel technique are needed before routine clinical use can be recommended.