Cholangioscopy-guided laser lithotripsy alongside a plastic stent for common bile duct stones after total gastrectomy

Peroral cholangioscopy (POCS)-guided lithotripsy in patients with surgically altered anatomy is challenging [1] [2]. Recently, a novel slim cholangioscope (9-Fr eyeMAX; Micro-Tech, Nanjing, China) has been developed that facilitates POCS-guided lithotripsy under balloon-enteroscopy assisted endoscopic retrograde cholangiopancreatography (BE-ERCP [3] [4]). However, the maneuverability of the cholangioscope is limited when the common bile duct is highly angulated. In such cases, inserting the cholangioscope alongside a plastic stent (PS) can improve maneuverability ([Fig. 1]). In addition, the PS allows excess saline to flow out of the bile duct, thereby preventing cholangitis. Herein, we report a successful case of POCS-guided laser lithotripsy performed alongside a PS in a patient with common bile duct stones after total gastrectomy ([Video 1]).

Fig. 1 Schemas of peroral cholangioscopy (POCS)-guided lithotripsy performed alongside a plastic stent. a Maneuverability of the cholangioscope is limited when the common bile duct is highly angulated. b In such cases, anchoring a plastic stent in the intrahepatic bile duct can straighten the common bile duct. c Inserting the cholangioscope alongside this stent improves maneuverability during POCS-guided lithotripsy. d Stone extraction is facilitated following POCS-guided lithotripsy of the large stone.

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Cholangioscopy-guided laser lithotripsy alongside a plastic stent was performed for common bile duct stones in a patient after total gastrectomy.Video 1

An 82-year-old man who had undergone total gastrectomy with Roux-en-Y reconstruction was referred to our hospital with cholangitis caused by large common bile duct stones ([Fig. 2]). First, BE-ERCP was performed for biliary drainage. The bile duct was highly angulated, and a double pigtail PS (7-Fr, 12 cm REGULUS double pigtail; Japan Lifeline, Co., Ltd, Tokyo, Japan) was placed with its proximal end anchored in the intrahepatic bile duct ([Fig. 3]). Six days later, POCS-guided lithotripsy was performed ([Fig. 4]). Cholangiography demonstrated that the bile duct was straightened. Subsequently, the 9-Fr eyeMAX cholangioscope was inserted alongside the PS and advanced easily to the perihilar bile duct. Laser lithotripsy was successfully performed using a holmium-YAG laser system (LithoEVO; Edap TMS, Lyon, France). After lithotripsy, the stent was removed, and stone extraction was performed using a basket catheter. Because the bile duct remained angulated, the 9-Fr eyeMAX cholangioscope was reinserted with difficulty. A residual stone was removed using a micro-basket catheter under cholangioscopy guidance. The patient was discharged without complications.

Fig. 2 Computed tomographic image showing a 15-mm stone in a highly angulated common bile duct.

Fig. 3 Fluoroscopic images of biliary stenting. a Biliary cannulation is performed using a rotatable papillotome, and the common bile duct is highly angulated. b A double-pigtail plastic stent (7-Fr, 12 cm) is placed with its proximal end anchored in the intrahepatic bile duct.

Fig. 4 a The 9-Fr eyeMAX cholangioscope is inserted alongside the plastic stent. b The 9-Fr eyeMAX cholangioscope is advanced easily to the perihilar bile duct. c Laser lithotripsy is successfully performed using a holmium-YAG laser system (LithoEVO, Edap TMS). d A residual stone is removed using a micro-basket catheter under cholangioscopy guidance.

To the best of our knowledge, this is the first report of POCS-guided lithotripsy performed alongside a PS, which improves the maneuverability of the cholangioscope.

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Contributorsʼ Statement

Ryo Soma: Conceptualization, Formal analysis, Visualization, Writing – original draft. Haruo Miwa: Conceptualization, Supervision. Kazuki Endo: Supervision. Ritsuko Oishi: Supervision. Yuichi Suzuki: Supervision. Hiromi Tsuchiya: Supervision. Shin Maeda: Supervision.

Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

The authors thank the endoscopy unit staff at Yokohama City University Medical Center for their assistance during the procedure. The authors declare that no external funding was received for this study.

• References

• 1 Hakuta R, Kogure H, Nakai Y. et al. Successful endoscopic lithotripsy using a new digital cholangioscope through an overtube placed by an enteroscope. Endoscopy 2018; 50: E269-E271
• 2 Tonozuka R, Itoi T, Sofuni A. et al. Novel peroral direct digital cholangioscopy-assisted lithotripsy using a monorail technique through the overtube in patients with surgically altered anatomy. Dig Endosc 2019; 31: 203-208
• 3 Kao KT, Batra B. Single-balloon-assisted ERCP with electrohydraulic lithotripsy for the treatment of a bile duct stone in a patient with a hepaticojejunostomy. Gastrointest Endosc 2014; 80: 1173
• 4 Sato T, Kogure H, Nakai Y. et al. Electrohydraulic lithotripsy under double-balloon endoscope-assisted direct cholangioscopy for treatment of choledocholithiasis in a patient with Roux-en-Y gastrectomy. VideoGIE 2018; 3: 113-114

Publication History

Article published online:
15 January 2026