LAUSR

IN PATIENTS WITH complicated hepatolithiasis, a multidisciplinary approach, including an endoscopist, a radiologist, and a surgeon is recommended as the management of hepatolithiasis with biliary stricture is challenging. A 44-year-old woman with a history of repetitive endoscopic retrograde cholangiopancreatography (ERCP)related procedures for biliary stones presented to our department with epigastralgia caused by bilateral hepatolithiasis (Fig. 1). She declined surgical treatment. Thus, an ERCP-related procedure was recommended. Cholangiography revealed a severe perihilar stricture, completely obstructed right hepatic duct, and hepatolithiasis in the left intrahepatic duct (Fig. 2). We decided to rescue at least the left lobe in the long term. First, we performed temporary bilateral intraductal drainages using a covered selfexpandable metallic stent (c-SEMS; 10 mm 9 60 mm BONASTENT M-Intraductal, Sewoon Medical, Cheonan-si, Korea) for the left lobe to facilitate stricture dilation and assist in subsequent digital single-operator cholangioscopy (D-SOC; SpyScope DS II, Boston Scientific, Marlborough, MA, USA) passage.We then used a plastic stent (7-Fr 9 90 mmThrough and Pass Inside Stent, Gadelius Medical, Tokyo, Japan) for the right lobe to prevent left focal cholangitis (Fig. 2). Twomonths later, D-SOC-guided electrohydraulic lithotripsy (EHL; Autolith Touch, Boston Scientific) for the left hepatolithiasis was performed through inside c-SEMS, followed by fragment retrieval using a balloon catheter without any complications (Fig. 2, Video S1). After removal of both stents, recanalization from the perihilum to the left hepatic duct was performed (Fig. 2, Video S1). The patient was discharged with an uneventful postoperative course after 2 days. D-SOC-guided EHL is a novel solution for difficult biliary stones. c-SEMS for benign biliary stricture showed promising results for biliary recanalization. In cases of hepatolithiasis with severe biliary stricture of the distal side, temporary placement of an intraductal c-SEMS ameliorated the stricture and enabled D-SOC-guided EHL. Authors declare no conflict of interest for this article.