A 39-year-old man who had undergone choledochojejunostomy with Roux-en-Y reconstruction
for congenital biliary dilatation was referred to our hospital with choledocholithiasis.
Computed tomography revealed large bile duct stones (BDS) in the hilum ([Fig. 1]
a). BDS removal was attempted using a double-balloon enteroscope (DBE); however, it
failed to crush the BDS, especially those in the right hepatic duct branch ([Fig. 1]
b). Percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy was performed;
however, complete stone clearance was not achieved because of the limited range of
motion of the cholangioscope caused by the BDS. Therefore, combined therapy comprising
endoscopic lithotripsy and percutaneous transhepatic cholangioscopy was planned to
maximize the effects of cholangioscopy with the support of the DBE ([Fig. 2], [Video 1]).
Fig. 1 Images showing multiple large bile duct stones in the hilum. a Computed tomography. b Cholangiography.
Fig. 2 Schematic diagram of combined approach. a Endoscopic lithotripsy under cholangioscopic monitoring. b Percutaneous transhepatic cholangioscopy for bile duct stones for which endoscopic
lithotripsy was difficult (circle). c Efficient stone removal through simultaneous water delivery from the cholangioscope
and absorption via the endoscope.
Combined therapy comprising endoscopic lithotripsy and percutaneous transhepatic cholangioscopy
for refractory choledocholithiasis.Video 1
Endoscopic stone removal was performed under cholangioscopic guidance. Subsequently,
percutaneous transhepatic cholangioscopy was attempted for BDS that could not be removed
by endoscopic lithotripsy; however, multiple small residual stones were identified
during cholangiography. Therefore, stone removal from the anastomosis to the jejunum
was performed using the force of water distributed from the biliary speculum and endoscopic
aspiration. The BDS were efficiently removed from the anastomosis, and complete stone
clearance was achieved ([Fig. 3]).
Fig. 3 Images showing complete stone clearance. a Computed tomography. b Cholangiography.
Although percutaneous transhepatic choledochoscopic electrohydraulic lithotripsy is
a useful treatment for refractory BDS [1]
[2]
[3], stone clearance can be difficult when the working space for the cholangioscope
is limited by large stones. An advantage of combined therapy comprising endoscopic
lithotripsy and percutaneous transhepatic cholangioscopy is that different approaches
using the endoscopic and percutaneous routes during the same session can performed
in difficult areas, thereby reducing the procedure time. This method allows efficient
stone removal using water delivery from the cholangioscope and water absorption via
the DBE.
In conclusion, combined therapy comprising endoscopic lithotripsy and percutaneous
transhepatic cholangioscopy is useful for refractory BDS.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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