A case of gallstone pancreatitis with a history of choledochojejunostomy treated by the endoscopic ultrasound rendezvous technique and stone removal from the residual bile duct

Gallstone pancreatitis necessitates emergency endoscopic removal of the responsible stone [1]. We report a case highlighting three significant clinical characteristics: 1) recurrent stone in the residual bile duct of the pancreatic head 13 years after choledochojejunostomy; 2) a challenging transpapillary approach to the buried papilla within a diverticulum; and 3) use of the endoscopic ultrasound rendezvous (EUS-RV) technique to access the bile duct. Successful stone removal alleviated the pancreatitis ([Video 1]).

Removal of a common bile duct stone from the residual bile duct in the pancreatic head using the endoscopic ultrasound rendezvous technique for gallstone pancreatitis in a patient with a history of choledochojejunostomy.Video 1

An 80-year-old man presented with abdominal pain. He had undergone choledochojejunostomy and cholecystectomy 13 years previously to remove common bile duct (CBD) stones and gallbladder stones. Computed tomography revealed a CBD stone in the residual bile duct of the pancreatic head and peripancreatic fluid collection ([Fig. 1] a). Endoscopic retrograde cholangiography was attempted for management of the gallstone pancreatitis; however, the orifice of the main papilla could not be located owing to the intradiverticular papilla ([Fig. 2]). The rendezvous technique was used to access the CBD. Given the history of choledochojejunostomy and post-cholecystectomy, EUS-RV via the intrapancreatic CBD was considered the sole curative method for CBD stone removal ([Fig. 1] b).

Fig. 1 Computed tomography (CT) findings during initial admission and diagram of the patient’s anatomy. a An 8-mm common bile duct (CBD) stone was detected (arrow), with accompanying peripancreatic fluid accumulation noted (arrowhead) on CT. b After choledochojejunostomy, the percutaneous transhepatic biliary drainage and endoscopic ultrasound (EUS)-guided hepaticogastrostomy routes could not access the residual bile duct. EUS-guided hepaticogastrostomy via the intrapancreatic CBD was therefore considered the sole curative method for removing the CBD stone. EUS-HGS, endoscopic ultrasound-guided hepaticogastrostomy; PTBD, percutaneous transhepatic biliary drainage; EUS-RV, endoscopic ultrasound rendezvous.

Fig. 2 Endoscopic findings from the initial endoscopic retrograde cholangiography procedure. The orifice of the main papilla could not be located owing to the presence of an intradiverticular papilla.

After EUS (UCT-260; Olympus Medical Systems, Tokyo, Japan) revealed an 8-mm CBD stone ([Fig. 3] a), the intrapancreatic CBD was punctured via the pancreas using a 19-G needle (EZ Shot 3 Plus; Olympus Medical Systems) ([Fig. 3] a). A 0.025-inch guidewire was then inserted into the CBD and advanced into the duodenum via the main papilla. We switched to a duodenoscope (TJF-Q290V; Olympus Medical Systems) and successfully cannulated the CBD after grasping the guidewire. The CBD stone was subsequently removed after endoscopic papillary large-balloon dilation ([Fig. 3] b–d, [Video 1]).

Fig. 3 Common bile duct (CBD) stone removal using the endoscopic ultrasound (EUS) rendezvous technique. a EUS showed an 8-mm CBD stone in the intrapancreatic CBD (arrow). The CBD was punctured through the pancreas. b Cholangiography after CBD puncture confirmed the presence of the CBD stone (arrow). c The guidewire was advanced into the duodenum via the papilla. d Successful cannulation of the CBD was achieved using the guidewire. The CBD stone was ultimately removed after endoscopic papillary large-balloon dilation. e After the procedure, an endoscopic nasobiliary drainage tube was placed in the CBD to prevent pancreatic juice leakage. The drainage tube was removed 3 days later, after confirming the absence of pancreatic leakage. CBDS, common bile duct stone.

As EUS-RV required puncturing through the pancreatic parenchyma, we placed an endoscopic nasobiliary drainage tube in the CBD to prevent leakage of pancreatic juice ([Fig. 3] e). No adverse events were observed, and the pancreatitis improved after the procedure.

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• Reference

• 1 Acosta JM, Katkhouda N, Debian KA. et al. Early ductal decompression versus conservative management for gallstone pancreatitis with ampullary obstruction: a prospective randomized clinical trial. Ann Surg 2006; 243: 33-40