Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
Journal website https://jocmr.elmerjournals.com

Original Article

Volume 18, Number 10, October 2026, pages 748-758

Single-Operator Cholangioscopy-Guided Electrohydraulic Lithotripsy for Difficult Common Bile Duct Stones: A Prospective Cohort Study of Efficacy, Safety, and Clinical Outcomes

Figures

↓  Figure 1. Fluoroscopic image obtained during ERCP demonstrating the single-operator cholangioscope (SpyGlass DS; Boston Scientific, Marlborough, MA, USA) positioned in direct contact with the target CBD stone; the arrow indicates the tip of the cholangioscope abutting the stone surface. CBD: common bile duct; ERCP: endoscopic retrograde cholangiopancreatography.
Figure 1.
↓  Figure 2. Fluoroscopic cholangiogram showing a large filling defect within the CBD, consistent with a difficult CBD stone; the arrow marks the stone’s proximal margin. CBD: common bile duct.
Figure 2.
↓  Figure 3. SpyGlass DS single-operator cholangioscope advanced into the CBD to perform EHL. The arrow indicates the cholangioscope tip within the ductal lumen. CBD: common bile duct; EHL: electrohydraulic lithotripsy.
Figure 3.
↓  Figure 4. Occlusion cholangiogram, obtained after SOC-guided EHL, confirming complete clearance of the CBD with no residual filling defect. CBD: common bile duct; EHL: electrohydraulic lithotripsy; SOC: single-operator cholangioscopy.
Figure 4.
↓  Figure 5. Direct cholangioscopic view during EHL probe lithotripsy, showing the EHL probe (arrow) applied to the stone surface under direct visualization through the single-operator cholangioscope. EHL: electrohydraulic lithotripsy.
Figure 5.
↓  Figure 6. Cholangioscopic image showing fragments of stones in front of EHL probe (arrow), generated by EHL immediately prior to extraction with a balloon sweeper or Dormia basket. EHL: electrohydraulic lithotripsy.
Figure 6.

Tables

↓  Table 1. Demographic and Clinical Characteristics of the Study Population (n = 25)
 
CharacteristicValue (n = 25)
ERCP: endoscopic retrograde cholangiopancreatography; HCV: hepatitis C virus; RUQ: right upper quadrant; SD: standard deviation; SVR: sustained virological response.
Age (years), mean ± SD61.8 ± 6.4
Age range (years)47–75
Sex, n (%)
  Male11 (44.0)
  Female14 (56.0)
Comorbidities, n (%)
  None15 (60.0)
  Hypertension7 (28.0)
  Diabetes mellitus6 (24.0)
  HCV (treated with SVR)3 (12.0)
  Ischemic heart disease1 (4.0)
  Bronchial asthma1 (4.0)
Clinical presentation, n (%)
  RUQ abdominal pain16 (64.0)
  Dyspepsia9 (36.0)
  Epigastric pain8 (32.0)
  Jaundice4 (16.0)
  Fever2 (8.0)
  Dark urine4 (16.0)
  Pale stool4 (16.0)
  Nausea/vomiting3 (12.0)
Gallbladder status, n (%)
  Post-cholecystectomy16 (64.0)
  Gallbladder in situ9 (36.0)
Previous ERCP, n (%)
  No previous ERCP1 (4.0)
  At least one prior ERCP24 (96.0)

 

↓  Table 2. Pre-Procedural Laboratory Parameters of the Study Population (n = 25)
 
ParameterMean ± SDReference rangeP-value
ALP: alkaline phosphatase; ALT: alanine aminotransferase; AST: aspartate aminotransferase; CRP: C-reactive protein; ESR: erythrocyte sedimentation rate; GGT: gamma-glutamyl transferase; INR: international normalized ratio; SD: standard deviation.
Hemoglobin (g/dL)12.68 ± 1.5112.0–16.0< 0.001
Total leukocyte count (× 103/µL)7.26 ± 2.274.0–11.00.602
Platelet count (× 103/µL)269.20 ± 97.47150–4000.769
ESR (mm/h)36.92 ± 8.720–20< 0.001
CRP (mg/L)10.00 ± 14.040–60.020
INR1.04 ± 0.090.8–1.20.036
AST (U/L)29.92 ± 16.4310–400.147
ALT (U/L)34.76 ± 19.117–560.402
Serum albumin (g/dL)4.21 ± 0.303.5–5.00.511
Direct bilirubin (mg/dL)0.65 ± 0.660.0–0.40.002
Total bilirubin (mg/dL)1.15 ± 0.750.2–1.20.006
ALP (U/L)196.64 ± 92.9240–129< 0.001
GGT (U/L)127.40 ± 59.059–48< 0.001
Serum creatinine (mg/dL)0.92 ± 0.210.6–1.20.638
Blood urea (mg/dL)31.92 ± 10.4215–450.366

 

↓  Table 3. Stone Characteristics and Imaging Findings (n = 25)
 
CharacteristicValue (n = 25)
CBD: common bile duct; MRCP: magnetic resonance cholangiopancreatography; SD: standard deviation.
Largest stone size (mm), mean ± SD15.6 ± 3.3
Stone size range (mm)5.0–22.0
Number of stones, n (%)
  Single stone11 (44.0)
  Multiple stones14 (56.0)
Stone location, n (%)
  Common bile duct25 (100.0)
  Common hepatic duct4 (16.0)
  Intrahepatic ducts4 (16.0)
Stone size category, n (%)
  > 15 mm15 (60.0)
  10–15 mm7 (28.0)
  < 10 mm3 (12.0)
Stone/duct ratio > 1, n (%)7 (28.0)
Impacted stones, n (%)1 (4.0)
Biliary dilation on imaging, n (%)24 (96.0)
Pre-procedural imaging, n (%)
  Transabdominal ultrasound25 (100.0)
  MRCP23 (92.0)

 

↓  Table 4. Procedural Outcomes and Complications (n = 25)
 
Outcome measureValue (n = 25)
CI: confidence interval; CRE: controlled radial expansion; ERCP: endoscopic retrograde cholangiopancreatography.
Primary outcome
  Complete stone clearance, n (%)22 (88.0)
  95% CI68.8–97.5%
Secondary outcomes
  Technical success (fragmentation), n (%)22 (88.0)
  Clinical success (complete clearance), n (%)22 (88.0)
  Procedural failure, n (%)3 (12.0)
Extraction method, n (%)
  Balloon extraction22 (88.0)
  Dormia basket4 (16.0)
Adjunctive procedures, n (%)
  CRE balloon dilation5 (20.0)
  Sphincteroplasty4 (16.0)
Post-procedural stenting, n (%)
  Single plastic stent20 (80.0)
  Double plastic stent5 (20.0)
Complications, n (%)
  Post-ERCP pancreatitis0 (0.0)
  Hemorrhage0 (0.0)
  Perforation0 (0.0)
  Cholangitis0 (0.0)
  Anesthesia-related adverse events0 (0.0)