Biliary stones are usually found in the gallbladder or in the biliary ducts and are
sometimes challenging to destroy with mechanical, electrohydraulic, or laser lithotripsy
[1]
[2]. Gallstone collections in the jejunal limb after duodenopancreatectomy have rarely
been reported in the literature [3]
[4].
We report here the case of a 66-year-old patient with an endocrine tumor that had
been previously resected by pancreatoduodenectomy (Imanaga’s procedure) in 1998. In
2014, she was referred for cholangitis and percutaneous radiologic drainage was performed.
Biliary stones were removed and an annual drainage was performed to gauge the biliojejunal
anastomosis. In 2017, she had several further episodes of cholangitis, with acute
pain in the hepatic region and fever. An abdominal computed tomography (CT) scan revealed
a 5-cm radiopaque stone in the afferent jejunal loop ([Fig. 1]), which was causing bile duct dilatation.
Fig. 1 Abdominal computed tomography scan showing the large endoluminal stone: a in transverse section; b in coronal section.
On endoscopy, the gastrojejunal anastomosis was found to be stenosed. We performed
endoscopic balloon dilation up to 12 mm in order to reach the afferent loop, which
had the giant intraluminal stone within it. After failure of several endoscopic techniques,
including argon plasma coagulation and electromechanical lithotripsy, we decided to
use the tip of a 10-mm polypectomy snare (Olympus, Tokyo, Japan) and Autocut mode,
at 180 W (ERBE VIO 300, Tübingen, Germany) in order to fragment the stone ([Video 1]). This allowed 80 % destruction of the stone and a second session was performed
1 month later.
Video 1 Endoscopic destruction of a large intrajejunal stone using the tip of a polypectomy
snare, a procedure repeated after 1 month, resulting in normal caliber bile ducts
on follow-up 8 months later.
The patient had an immediate clinical response following the first procedure. After
8 months of follow-up, no further episodes of cholangitis have been reported and biliary
magnetic resonance imaging (MRI) shows normal caliber bile ducts ([Fig. 2]).
Fig. 2 Biliary magnetic resonance imaging scan 8 months after the procedure showing normal
caliber bile ducts.
In conclusion, we report a rare complication after an Imanaga’s reconstruction procedure
that was treated endoscopically. Our case was particularly difficult because of the
giant size of the intrajejunal stone (5 cm). Large stone destruction can be possible
using the tip of a snare with a high Autocut mode (180 W), in order to avoid a difficult
surgical approach.
Endoscopy_UCTN_Code_TTT_1AP_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
