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We report a clinical case series of five patients with choledocholithiasis and anatomic abnormalities that made biliary access by endoscopic retrograde cholangiography (ERCP) impossible. In three patients, we were unsuccessful in accessing the biliary tract by single-balloon enteroscopy because of surgically altered anatomy with biliodigestive anastomosis. In two patients, a large diverticulum prevented intubation of the common bile duct. All of the patients presented with signs of cholestasis including elevated bilirubin levels. Magnetic resonance imaging (MRI) scans revealed one to three large stones in the main or intrahepatic bile duct. Different approaches for such patients have been described [1–3]. We primarily used a percutaneous approach (▶Fig. 1); however, the stones were too hard and/or too large to be fragmented, retrieved, or transpositioned via percutaneous transhepatic cholangiography. An 8.5-Fr drain was inserted and was subsequently replaced by a 12-Fr percutaneous transbiliary drain to enlarge the insertion site. The drain was changed to a 12-Fr sheath, which was placed in the upper main bile duct or in an intrahepatic bile duct ▶Fig. 2). The bile duct was directly entered via this inlet with a cholangioscope (SpyGlass Direct Visualization System; Boston Scientific, Natick, Massachusetts, USA). Endoscopic biliary access was possible at a mean of 4 days after the initial percutaneous drainage. The stones were directly fragmented under optic visualization using an electrohydraulic lithotripsy device (P2,4/3000/f probe; Walz Elektronik GmbH, Rohrdorf, Germany) [4] (▶Fig. 3). All fragments were completely removed by flushing E-Videos

Cholangioscopy-guided electrohydraulic lithotripsy of large bile duct stones through a percutaneous access device