Peroral direct cholangioscopy using balloon endoscopy for massive bile duct stones after Roux-en-Y hepaticojejunostomy

A 63-year-old man with acute cholangitis was admitted to our hospital. He had undergone pancreaticoduodenectomy with Roux-en-Y hepaticojejunostomy for a duodenal ulcer 13 years previously. The patient was referred to our hospital for stone extraction after undergoing endoscopic retrograde cholangiopancreatography with plastic biliary stent placement.

Computed tomography revealed several stones (maximum size 30 mm) in multiple dilated biliary branches ([Fig. 1]). We first attempted conventional endoscopic lithotomy, which failed due to the multiple large stones. Therefore, we performed peroral direct cholangioscopy (PDCS) to remove the bile duct stones ([Video 1]). After reaching the anastomosis using a short-type, single-balloon endoscope (SBE, SIF-H290S; Olympus Medical System, Tokyo, Japan), we expanded the anastomosis with a large-diameter balloon (Giga 12–14 mm; Century Medical, Tokyo, Japan) and inserted the SBE directly into the bile duct. The stones were crushed using electric hydraulic lithotripsy (Nortech Autolith lithotripter with a 1.9 Fr probe; Northgate Technologies, Elgin, Illinois, USA) under saline solution irrigation using an irrigation valve (BioShield irrigator; US Endoscopy, Mentor, Ohio, USA) connected to a water pump, which allowed immediate, intraprocedural, and hands-free (foot pedal control) irrigation with the device in the channel. The stones were then completely removed using a basket catheter and retrieval net under direct visualization ([Fig. 2]).

Fig. 1 Computed tomography images. a, b Many stones, with a maximum size of 30 mm, were seen in multiple biliary dilated branches (arrows).

Video 1 Massive bile duct stones were removed with peroral direct cholangioscopy using a single-balloon endoscope after Roux-en-Y hepaticojejunostomy.

Fig. 2 Endoscopic views. a, b The stones were crushed using electrohydraulic lithotripsy, and removed using a basket catheter and retrieval net (arrow; electrohydraulic lithotripsy probe). These procedures were performed by direct visualization (SIF-H290S; Olympus Medical System, Tokyo, Japan). c No residual stones were confirmed via endoscopic view.

The usefulness of PDCS for the confirmation and removal of residual stones has been reported [1]. Ultraslim endoscopes are usually used for PDCS [2]; however, conventional endoscopes often do not reach the duodenal papilla or anastomosis in patients with surgically altered anatomy. Because the channel diameter of the SBE is large, it has the advantages of enabling the use of various devices and strong suction power [3]. In hepaticojejunostomy cases, a frontal view of the anastomosis is often obtained. Therefore, lithotomy with PDCS using SBE should be considered an effective treatment for difficult stones with lower bile duct dilation.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Itoi T, Sofuni A, Itokawa F. et al. Evaluation of residual bile duct stones by peroral cholangioscopy in comparison with balloon-cholangiography. Dig Endosc 2010; 22: S85-S89
• 2 Moon JH, Ko BM, Choi HJ. et al. Direct peroral cholangioscopy using an ultra-slim upper endoscope for the treatment of retained bile duct stones. Am J Gastroenterol 2009; 104: 2729-2733
• 3 Yamauchi H, Kida M, Okuwaki K. et al. Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos). Surg Endosc 2018; 32: 498-506

Publikationsverlauf

Artikel online veröffentlicht:
11. November 2022