DIRECT PERORAL CHOLANGIOSCOPY FOR DIFFICULT BILIARY STONES TREATMENT DIRECT PERORAL CHOLANGIOSCOPY IN DIFFICULT BILIARY STONES

Introduction:

Peroral cholangioscopy (POC) using a conventional endoscope allows better visualization of the biliary tree and the use of devices that are not possible with the duodenoscope and is a useful technique for the treatment of difficult biliary lithiasis' cases. The authors describe one of these cases, resolved using POC and polypectomy snare.

Cases Report:

A 76-year-old female, with a medical history of liver transplant in 1991 for primary biliary cholangitis, which was complicated with an anastomotic stricture. She had been previously submitted to four endoscopic retrograde cholangiopancreatography (ERCP), including two direct POC procedures (between 2009 – 2016) due to episodes of symptomatic choledocholithiasis/cholangitis. In the previous procedure, balloon catheter passage and POC with mechanical lithotripsy failed to remove the largest stones and a plastic stent of 10Fr and 4 cm was placed, to permit biliary drainage and provoke mechanic fragmentation of the impacted stones. Three months later, POC was repeated with a conventional videogastroscope (Olympus GIF-Q180), and identified a biliary stone distal to the anastomosis, which was removed with a Roth net retriever. Cholangiogram confirmed the persistence of a subtraction defect of 20 mm, proximal to the anastomosis. Mechanical lithotripsy (Olympus BML-110) was attempted without success. Then anastomosis dilatation up to 15 mm (Boston Scientific Wire guided Balloon Dilator) was performed, under direct and fluoroscopic control. Subsequently, the conventional endoscope was introduced proximal to the anastomosis with direct visualization of the calculus, which was successfully removed recurring to a polypectomy snare (Olympus SnareMaster). Final cholangiogram revealed no subtraction defects, with proper drainage at the end of the procedure.