[An extremely elderly patient with choledocholithiasis and many complications]

Area of Science:

• Gastroenterology and Hepatology
• Interventional Endoscopy

Background:

• Choledocholithiasis with acute obstructive suppurative cholangitis and gallbladder perforation presents significant treatment challenges, especially in elderly patients.
• Management requires a multi-faceted approach to address biliary obstruction, infection, and gallbladder integrity.

Observation:

• A 90-year-old female patient presented with severe choledocholithiasis, acute obstructive suppurative cholangitis, and gallbladder perforation with a perirenal bile collection.
• Initial attempts at extracorporeal shockwave lithotripsy (ESWL) following percutaneous transhepatic biliary drainage (PTBD) were unsuccessful due to large, hard stones.

Findings:

• Endoscopic sphincterotomy (EST) was performed using an ultratome via a rendezvous technique.
• Multiple endoscopic mechanical lithotripsy (EML) sessions and the use of an endotriptor were required to successfully fragment and clear the impacted stones.
• A staged, step-by-step endoscopic strategy was crucial for successful treatment.

Implications:

• This case highlights the feasibility and importance of a meticulously planned, stepwise endoscopic approach for managing complex biliary conditions in frail, elderly patients.
• Advanced endoscopic techniques, including mechanical lithotripsy, can overcome challenges posed by large or impacted stones, offering a less invasive alternative.
• Careful patient selection and procedural sequencing are paramount for optimizing outcomes in high-risk populations.