Endoscopy 2021; 53(06): E230-E231
DOI: 10.1055/a-1244-9556
E-Videos

A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal

Toshihiro Homma
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
,
Kenjiro Yamamoto
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
,
Takayoshi Tsuchiya
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
,
Ryosuke Tonozuka
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
,
Hirohito Minami
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
,
Eri Joyama
2  Department of International medicine, Tokyo Medical University Hospital, Tokyo, Japan
,
Takao Itoi
1  Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan
› Author Affiliations
 

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is useful for the treatment of bile duct stones in patients with surgically altered anatomy [1] [2] [3]; however, the procedure cannot always successfully remove stones when the anastomotic site or papilla of Vater cannot be reached. Recently, endoscopic ultrasound (EUS)-guided antegrade intervention has been developed for benign biliary diseases, including hepatolithiasis in patients with altered anatomy [4] [5]. We report a case of EUS-guided transhepatic antegrade stone removal (EUS-TASR) in a patient with altered anatomy ([Video 1]).

Video 1 Endoscopic ultrasound-guided transhepatic antegrade stone removal was useful for severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction.


Quality:

The 59-year-old man underwent hepaticojejunostomy with Roux-en-Y reconstruction for hepatolithiasis several years previously. He was referred to our hospital for treatment of severe hepatolithiasis. Abdominal computed tomography showed huge impacted stones in the hilum and a dilated left intrahepatic bile duct ([Fig. 1 a] ).

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Fig. 1 Computed tomography. a Before treatment, showing huge impacted stones in the hilum and a dilated left intrahepatic bile duct. b After the procedure, showing complete clearance.

We chose to perform EUS-TASR because accessing the anastomotic site by balloon-assisted ERCP was judged to be difficult owing to the long afferent loop and because multiple sessions would be required for stone removal.

We first performed EUS-guided hepaticogastrostomy (EUS-HGS). The dilated left intrahepatic bile duct was punctured using a 19-gauge fine-needle aspiration needle from the residual stomach side. Cholangiography showed multiple impacted stones from the hilum to the bilateral intrahepatic bile ducts. A 0.025-inch guidewire was inserted into the intrahepatic bile duct and the needle tract was dilated using an ultra-tapered mechanical dilator. A fully covered metal stent was then placed over the guidewire ([Fig. 2]).

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Fig. 2 Endoscopic ultrasound-guided hepaticogastrostomy.

EUS-TASR was performed 1 month later. After dilation of the anastomotic stricture using a balloon catheter, a cholangioscope was inserted into the intrahepatic bile duct through the metal stent. Bile duct stones were crushed using electrohydraulic lithotripsy under direct visualization ([Fig. 3]). Subsequently, stone fragments were removed using a basket catheter and balloon catheter through the anastomotic route and HGS route ([Fig. 4]). Finally, the huge hepatic bile duct stone was completely removed ([Fig. 1 b]).

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Fig. 3 Bile duct stones were crushed using electrohydraulic lithotripsy under direct visualization.
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Fig. 4 Stone fragments were removed using a basket catheter through the hepaticogastrostomy route under direct visualization.

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Correction

A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal
Homma T, Yamamoto K, Tsuchiya T et al. A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal. Endoscopy 2020, 52: 10.1055/a-1244-9556
In the above-mentioned article, the institution of Takao Itoi has been corrected. This was corrected in the online version on September 30, 2020.


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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Kenjiro Yamamoto, MD
Department of Gastroenterology and Hepatology
Tokyo Medical University
6-7-1, Nishishinjuku
Shinjuku-ku, Tokyo 160-0023
Japan   
Fax: +81-3-53816654   

Publication History

Publication Date:
23 September 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomography. a Before treatment, showing huge impacted stones in the hilum and a dilated left intrahepatic bile duct. b After the procedure, showing complete clearance.
Zoom Image
Fig. 2 Endoscopic ultrasound-guided hepaticogastrostomy.
Zoom Image
Fig. 3 Bile duct stones were crushed using electrohydraulic lithotripsy under direct visualization.
Zoom Image
Fig. 4 Stone fragments were removed using a basket catheter through the hepaticogastrostomy route under direct visualization.