Endoscopic retrograde cholangiography has been the criterion standard treatment of bile duct stones since 1974. 1,2 Use of standard endoscopic techniques such as sphincterotomy, extraction balloon, basket, or mechanical lithotripsy have been successful in approximately 90% of these patients. [3][4][5] Electrohydraulic (EHL) [6][7][8] and laser lithotripsy [9][10][11][12] were introduced in the mid-1980s as new treatment modalities for the 10% to 15% of patients with refractory stones and were found to be very effective. Because of the increased risk of heat-induced perforation, these techniques have been performed under either direct cholangioscopic visualization 7-10 or fluoroscopically with a stone/tissue detection system. 13,14 Because both systems were essentially limited to only major medical centers, EHL and laser lithotripsy have been used sparingly.
Single-operator steerable cholangioscopy (SOC) now permits the routine use of these technologies. Several lasers have been developed over the years for intraductal lithotripsy: pulsed-dye (coumarin green and rhodamine-6G) and pulsed solid state (neodymium-yttrium aluminum garnet [Nd-YAG]), frequency-doubled double-pulse yttrium aluminum garnet [FREDDY], alexandrite, and holmium: yttrium aluminum garnet [Ho:YAG]). Of these, the holmium laser is the newest laser lithotrite to be introduced to stone fragmentation. The aim of our study was to determine the safety and efficacy of this new technology in patients with difficult bile duct stones refractory to conventional endoscopic methods.