Abstract
While there are reports on the use of Electrohydraulic Lithotripsy (EHL) in the treatment of gallstone ileus since 1997, this is the first case demonstrating the successful destruction of an obstructing gallstone at a colo-colonic anastomosis. Surgical management of gallstone ileus remains a procedure with potentially high morbidity and mortality. Here we present the successful use of EHL on an obstructing colonic gallstone reaffirming its safety and efficacy and broadening its potential use. A 55-year-old female presented with a two-week history of lower abdominal pain and distension. Past medical history was significant for cholelithiasis and perforated diverticulitis requiring multiple surgeries: sigmoid colectomy with loop ileostomy, subsequent anastomosis revision, and closure of the ileostomy. Physical exam revealed an obese abdomen diffusely tender to palpation. Computed tomography showed a gallstone at the rectosigmoid junction proximal to a focal area of narrowing and similar in size to one previously noted in the gallbladder. The proximal colon was distended and pneumobilia noted. Findings were consistent with colonic obstruction due to a gallstone at a colonic stricture. Due to her complicated surgical history, endoscopic intervention was chosen. Using a pediatric colonoscope, we identified a 3 cm gallstone above a 6 mm intrinsic stenosis located 20 to 24 cm proximal to the anus. The stricture was dilated to 12 mm using a CRE balloon and the stone was secured inside an extraction basket. Mechanical lithotripsy (ML) failed due to rupture of multiple baskets and the procedure was terminated. A second session employed EHL, but resulted in only a few small holes in the stone while ML again resulted in broken baskets. On third attempt the stone was secured in a roth net, moved to the cecum and EHL was performed using 5-15-60, 20-15-80 and 20-15-100 (blast-seconds-watts) settings and resulting in a medium size crater and few stone fragments. The remains were crushed using ML and removed with extraction baskets. The two technical difficulties using EHL in her case: keeping the stone immobile while performing EHL and maintaining an interface of water and stone required for EHL were mitigated by moving the stone from the left colon to cecum. While EHL is typically reserved for endoscopic fragmentation of biliary and pancreatic duct stones, here we reaffirm its use for the management of colonic gallstones, including complex mobile and/or distal stones.