DBE-ERCP, DIRECT CHOLANGIOSCOPY WITH LITHOTRIPSY AND OVERTUBE-ASSISTED PLACEMENT OF A METAL STENT INTO THE BILE DUCT OF A PATIENT WITH SURGICALLY ALTERED UPPER GI ANATOMY

An octogenarian female with complex post-surgical upper GI anatomy and recalcitrant choledocholithiasis underwent double-balloon ERCP to clear the bile duct, which was dilated, tortuous and distally stenotic. A sphincteroplasty using a 15 mm CRE balloon was performed. Then a successful electrohydraulic lithotripsy (EHL) was delivered through an ultraslim gastroscope, which had been advanced into the bile duct through the overtube. After EHL large amounts of sludge and stones could be removed. Nevertheless, complete clearance of the stones was unobtainable and the decision was made to place a 10 mm diameter, 60 mm long fully covered SEMS. The stent delivery system diameter was too large for the working channel of either an enteroscope or gastroscope. Therefore, a biliary guidewire was delivered deep into the bile duct system through the gastroscope, then the scope was exchanged, leaving the overtube and wire in place. A stent was subsequently placed over the guidewire, using the overtube, which served as a “large diameter-working channel”. Advancement and release of the stent was done under fluoroscopic control. After removal of the guidewire and delivery system, the enteroscope was passed through the overtube, still in place, and the stent was directly visualized in the correct location with outflow of sludge, bile, and contrast. The patient had an uneventful recovery and the SEMS was removed six months later, with resolution of the chledocolithiasis and distal CBD stricture. This case exemplifies a case of extreme ERCP, were multiple scopes and devices were mandatory to solve a complex biliary problem. We believe that the multiple techniques portrayed in this this case are useful, and may enhance the therapeutic arsenal of the biliary endoscopist.