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Background Single operator cholangioscopy guided electrohydraulic lithotripsy (SOC-EHL) is effective in difficult biliary stones. SOC is usually introduced in a transpapilliary fashion via a duodenoscope (peroral SOC). This approach is limited in intrahepatic ductal access, especially in presence of distal strictures. Aims To report a case of ductal clearance using a unique percutaneous access of SOC-EHL in a patient with extensive intrahepatic stones in addition to a distal stricture. Methods A retrospective case report Results An 80 year old male known for a distal cholangiocarcinoma post-Whipple surgery presented with recurrent cholangitis. Computed tomography scan revealed dilated intrahepatic bile ducts in segments V and VII and a dilated posterior right hepatic duct (PRHD) with associated cholelithiasis. Peroral SOC was first performed using a therapeutic gastroscope. The hepaticojejunostomy was patent and the cholangioscope was easily introduced into the bile duct. No stones or strictures were found on inspection of the intra- and extra-hepatic biliary system. Due to cholangitis recurrence a left-sided percutaneous drain was placed. However, cholangiogram showed a normal biliary sytem with no filling defects. A right-sided PTC was then performed for source control. Repeat right-sided cholangiogram finally identified an extremely dilated PRHD with extensive filling defects and a stricture in the distal PRHD. The abnormal biliary segments were missed on peroral SOC and left-sided cholangiogram due to the tight stricture. Percutaneous SOC-EHL was then planned. The abnormal segment could not be reached using the right sided access. The left system did not allow for easy PRHD access due to the stricture and angulation. In order to gain entry to the abnormal biliary segment, the PRHD stricture was dilated to 6mm with balloon angioplasty. A 0.035” guidewire was inserted from the left access and advanced to the extrahepatic bile duct. This wire was captured using a snare introduced from the right percutaneous access and pulled through the right side. This allowed wire tension to be optimally applied from both percutaneous accesses. A cholangioscope was then introduced over the wire from the left access and advanced into the abnormal PRHD with optimal wire tension at both ends. A large stone burden was noted on SOC and ductal clearance with EHL was achieved after two EHL sessions (Fig. 1). Final cholangiogram showed complete ductal clearance and there was no recurrence of cholangitis at an 18 month follow-up. Conclusions SOC-EHL is an important therapeutic modality but may be of limited effectivess for extensive intrahepatic stones. Our case suggests the possibility of using a percutaneous approach for SOC-EHL in intrahepatic stones with concomitant distal stricture. Figure 1: A) Cholangiogram showing extensive intrahepatic stone burden; B) SOC-EHL via a percutaneous access with EHL; C) final cholangiogram showing complete ductal clearance. Funding Agencies None

journal of the canadian association of gastroenterology

A204 SINGLE OPERATOR CHOLANGIOSCOPY GUIDED ELECTROHYDRAULIC LITHOTRIPSY THROUGH A UNIQUE PERCUTANEOUS ACCESS FOR SEVERE RECURRENT PYOGENIC CHOLANGITIS: A CASE REPORT