Tolerability and safety of cholangioscopy and lithotripsy under conscious sedation for refractory choledocholithiasis: experience in a cohort of elder or co-morbid patients

Aims Cholangioscopy with electrohydraulic lithotripsy (C+EHL) is an effective treatment for choledocholithiasis refractory to conventional endoscopic retrograde cholangiopancreatography (ERCP). Complexity and long duration of the procedure has traditionally required the use of general anaesthesia (GA), but older patients with co-morbidities may not be candidates for this. We assessed the tolerance, safety and efficacy of C+EHL under conscious sedation for refractory choledocholithiasis in a cohort of patients with these characteristics.

Methods Retrospective analysis of C+EHL procedures under conscious sedation from October 2022 to September 2023 performed in a tertiary centre. ERCP Spyglass DS1 (Boston) and Autolith Touch II EHL Generator were used for all procedures.

Results 15 C+EHLs were performed in 12 patients. Mean age was 77.25 years (range 59-93) and M:F ratio was 10:2. Seven (58%) were tertiary referrals. Major co-morbidities included cardiovascular (42%), respiratory (42%) and cerebro-vascular (25%). Patients had 0-3 (mean 1.3) conventional ERCPs prior to C+EHL. Patents were selected for conscious sedation based on existing internal protocols for GA and one-to-one assessments of tolerability based on prior conventional ERCP experience. All procedures were done under conscious sedation using intravenous Fentanyl and Midazolam. Mean Fentanyl dose was 120 mcg (range 75-200) and the mean Midazolam dose was 4.75mg (range 3-8). No reversal agents were required. Mean time for procedure was 58 minutes (range 34-86). A mean of 1.25 procedures were required to achieve duct clearance (range 1-3). Tolerance scores were reported by nursing team: minimal discomfort in 1 procedure (7%), mild discomfort in 5 (33%), moderate discomfort for 7 (47%), severe discomfort for 1 (7%); the score was not documented for 1 procedure (7%). Patients were also contacted by telephone and asked to score their comfort level subjectively: no discomfort was reported in 10 cases and mild discomfort in 2; 2 patients could not be contacted and one patient had subsequently died (not related to C+EHL). There were no complications in the 15 procedures. One patient had transient oxygen desaturation but recovered spontaneously. 11 patients were admitted for intravenous antibiotics for 24hrs post-procedure except 1 patient who refused admission.

Conclusions Spyglass EHL under conscious sedation is reasonably well tolerated – patients’ recall of discomfort was notably lower than contemporaneous nursing assessment. Moreover, our experience suggests it is safe and efficient. With the current paucity of available GA lists, an aging population and high anaesthetic risk due to comorbidities, C+EHL under conscious sedation is a feasible option. A robust MDT approach is required to ensure identification of suitable patients.

Publication History

Article published online:
15 April 2024