ENDOSCOPIC DESTRUCTION OF A LARGE INTRAJEJUNAL BILIARY STONE USING THE POLYPECTOMY SNARE AND HIGH AUTOCUT MODE

Biliary stones are usually found in the gallbladder or in the biliary ducts and are sometimes challenging to destroyed with mechanical, electrohydraulic or laser lithotripsy. Collection of gallstones in the jejunal limb after duodenopancreatectomy was rarely reported in the literature.

We report here the case of a 66 years-old woman followed up since 1998 after an Imanaga's procedure of pancreatoduodenectomy for an endocrine tumor. In 2014, she was referred for an angiocholitis and a percutaneous radiologic drainage was performed. Biliary stones were removed and a one-year drainage was maintained to calibrate the biliojejunal anastomosis. In 2017, she repeated angiocholitis with acute pain of the hepatic region. An abdominal CT scan revealed a 4 cm radiopaque stone in the afferent jejunal loop responsible of bile duct dilation.

Endoscopy showed a stenosis of the gastrojejunal anastomosis not passable initially with a scope. After a 12 mm balloon dilatation we explored the afferent loop and found immediately an enormous yellow stone. The capture of the stone was impossible with a 40 mm snare and we thus decided to destroy the stone. We first tried argon plasma coagulation and electromechanical lithotrity but without any effectiveness on the stone. Finally, the tip of a 10 mm snare (Olympus, Tokyo, Japan) was used to damage the stone using the Autocut mode 180W (Erbe, Tuebingen, Germany) to drill and fragment this stone.

After 2 hours of procedure, 80% of the stone were destroyed and we decided to schedule a second endoscopic session. Pain disappeared immediately after the first session and 1 month later, a 1 cm stone remained which was easily fragmented with the same technique.

In conclusion, we report an extremely rare complication after Imanaga's procedure treated by endoscopy. Autocut mode 180 watt applied with tip of the snare is a possible technique to split stones to avoid difficult surgery approach.