Endoscopic ultrasound-guided antegrade biliary intervention for choledocholithiasis in total gastrectomy with Roux-en-Y anatomy

Endoscopic retrograde cholangiopancreatography in patients with a history of total gastrectomy and Roux-en-Y anastomosis is challenging due to the difficulty in locating the papilla [1] [2]. Meanwhile, increased intestinal motility and the considerable distance between the anastomosed limb and the left hepatic lobe also contribute to the failure in identifying a suitable puncture path during endoscopic ultrasound (EUS)-guided biliary drainage in these patients. Therefore, selecting a favorable puncture path for the left liver in the appropriate postoperative bowel is the key to successful EUS procedures.

A 77-year-old woman with a history of total gastrectomy and Roux-en-Y reconstruction for gastric cancer was admitted to our hospital with abdominal pain. Magnetic resonance imaging revealed choledocholithiasis ([Fig. 1]). The duodenal papilla was not located on initial endoscopy despite use of a gastroscope, colonoscope, and enteroscope. Subsequently, a linear echoendoscope was inserted into the jejunum through the anastomosis. Both afferent and efferent limbs were examined to identify an optimal puncture site for accessing the intrahepatic bile duct ([Fig. 2]). Eventually, the intrahepatic bile duct in liver segment S2, within the afferent limb, was selected. The mildly dilated left intrahepatic bile duct (approximately 0.4 cm) was accessed using a 19-gauge puncture needle ([Video 1]). Cholangiography revealed a stone in the common bile duct (CBD). A guidewire was inserted; however, antegrade advancement into the distal CBD was challenging. Consequently, a 6-Fr cystotome was advanced over the guidewire for tract dilation. The distal CBD was successfully accessed, and the guidewire was advanced through the duodenal papilla into the duodenal lumen. A dilation balloon was used to expand the duct to 1.0 cm sequentially ([Fig. 3]); the stone was extracted into the duodenal lumen using a retrieval balloon. Finally, a 7 Fr × 15 cm double-pigtail biliary stent was placed, with two ends in the duodenal and jejunal lumens, respectively ([Fig. 4]).

Fig. 1 Magnetic resonance imaging revealed a stone in the common bile duct and mild dilation of the upstream duct (indicated by the yellow arrow).

Fig. 2 In the endoscopic view, the efferent limb is on the left, and the afferent limb is on the right.

Fig. 3 A dilation balloon was used to expand the common bile duct (CBD). The arrow points to a stone in the CBD.

Fig. 4 A double-pigtail biliary stent was placed, with two ends in the duodenal and jejunal lumens, respectively.

Endoscopic ultrasound-guided antegrade biliary intervention for choledocholithiasis in total gastrectomy with Roux-en-Y anatomy.Video 1

Postoperatively, the patient’s serum lipase and amylase levels remained within normal limits, whereas bilirubin levels showed a mild transient elevation that normalized within 3 days. The patient was discharged 1 week after surgery.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Iwashita T, Yasuda I, Doi S. et al. Endoscopic ultrasound-guided antegrade papillary balloon dilation for treating a common bile duct stone. Dig Endosc 2013; 25: 89-90
• 2 Itoi T, Sofuni A, Tsuchiya T. et al. Endoscopic ultrasonography-guided transhepatic antegrade stone removal in patients with surgically altered anatomy: case series and technical review (with videos). J Hepatobiliary Pancreat Sci 2014; 21: E86-E93

Publication History

Article published online:
09 July 2025