Endoscopic ultrasound-guided antegrade bile duct stone treatment followed by direct peroral transhepatic cholangioscopy in a patient with Roux-en-Y reconstruction

Endoscopic ultrasound (EUS)-guided antegrade treatment for biliary disorders was developed for patients with an altered anatomy [1] [2] [3] [4] [5]. This report describes a case of successful EUS-guided bile duct stone (BDS) treatment followed by direct peroral transjejunal-hepatic cholangioscopy in a patient with Roux-en-Y reconstruction.

An 80-year-old woman with a BDS and a history of total gastrectomy with Roux-en-Y reconstruction was admitted to the Hokkaido University Hospital. The papilla could not be reached even with balloon enteroscopy. Therefore, transhepatic EUS-guided antegrade BDS treatment was attempted.

A B3 branch duct was punctured using a 19-gauge needle (SonoTip Pro Control; Medi-Globe GmbH, Rosenheim, Germany), and a 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was placed ([Video 1]). A 6-Fr wire-guided diathermic dilator (Cysto-Gastro-Set; Endo-Flex GmbH, Voerde, Germany) was used to dilate the tract. Papillary balloon dilation (Hurricane RX Biliary Balloon Dilatation Catheter; Boston Scientific Japan, Tokyo, Japan) was also performed under fluoroscopic guidance according to the size of the distal bile duct ([Fig. 1 a], [Video 1]). The retrieval balloon (Extractor Pro RX retrieval balloon catheter, 15 – 18 mm; Boston) and mechanical lithotripter (Litho Crush V, BML-V437QR-30; Olympus) both failed to extract the stone ([Video 1]). A 6-Fr nasobiliary drainage catheter (NBDC; Flexima ENBD Catheter; Boston Scientific Japan) was placed across the papilla for drainage into the duodenum and to facilitate a rendezvous procedure using balloon enteroscopy ([Fig. 1 b]).

Endoscopic ultrasound (EUS)-guided bile duct stone (BDS) treatment and direct, peroral, transjejunal-hepatic cholangioscopy in a patient with Roux-en-Y reconstruction. First, EUS-guided antegrade papillary balloon dilation was performed using a standard balloon catheter. An attempt was made to retrieve the stone using the balloon catheter. The attempt failed and a nasobiliary catheter was placed across the papilla for drainage. Second, an attempt was made to retrieve the stone using a standard basket catheter. Third, this attempt at stone retrieval also failed and therefore emergency, direct, peroral lithotripsy using a mechanical lithotriptor was performed to crush the stone. An endoscopic antegrade nasobiliary catheter was placed. Finally, direct, peroral, transhepatic cholangioscopy was performed 6 days later to confirm clearance of stones or debris.

Fig. 1 Endoscopic ultrasound (EUS)-guided bile duct stone (BDS) treatment and direct, peroral, transjejunal-hepatic cholangioscopy in a patient with Roux-en-Y reconstruction. a Radiograph showing endoscopic ultrasound-guided standard papillary balloon dilation under fluoroscopic guidance. b Radiograph showing an endoscopic ultrasound-guided nasobiliary drainage catheter placed across the papilla. Inset: endoscopic image. c Radiograph showing a basket catheter that failed to advance across the papilla. d Radiograph showing an impacted bile duct stone crushed using peroral direct lithotripsy. e Radiograph showing direct, peroral, transhepatic cholangioscopy after endoscopic ultrasound-guided biliary drainage.

The next day, the patient developed acute cholangitis. Re-intervention through the fistula tract was attempted. After advancing the guidewire into the bile duct, the BDS was captured by a standard basket catheter (FG-V435P; Olympus) ([Fig. 1 c], [Video 1]). However, the basket catheter could not pass the papilla and was impacted instead ([Video 1]). Emergency, direct, peroral lithotripsy (BML-110A-1; Olympus) was performed ([Fig. 1 d], [Video 1]). After the BDS had been crushed, the NBDC was inserted into the bile duct without complications. At follow-up 6 days later, direct, peroral transhepatic cholangioscopy (CHF-B260, working channel 1.2 mm; Olympus) was performed under therapeutic duodenoscope (TJF-260V; Olympus) guidance, and complete BDS clearance was confirmed ([Fig. 1 e], [Video 1]).

An EUS-guided rendezvous procedure is generally performed when EUS-guided antegrade BDS treatment fails. However, endoscopic re-intervention through the fistula tract should be considered in patients with altered gastrointestinal anatomy. To our knowledge, this is the first report of a troubleshooting technique for BDS impaction using direct, peroral, mechanical lithotripsy and confirmation of BDS clearance by direct antegrade cholangioscopy following EUS-guided biliary drainage. Although challenging, this stone extraction technique combined with EUS-guided antegrade cholangiography and cholangioscopy (EUS-guided ACC) should be recognized as a treatment for BDS in patients with altered gastrointestinal anatomy.

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• References

• 1 Weilert F, Binmoeller KF, Marson F et al. Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass. Endoscopy 2011; 43: 1105-1108
• 2 Iwashita T, Yasuda I, Doi S et al. Endoscopic ultrasound-guided antegrade treatments for biliary disorders in patients with surgically altered anatomy. Dig Dis Sci 2013; 58: 2417-2422
• 3 Itoi T, Sofuni A, Tshichiya 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: E86-93
• 4 Kawakami H, Kuwatani M, Kawakubo K et al. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metal stent placement for malignant distal biliary stricture. Endoscopy 2014; 46 (Suppl. 01) E328-E329
• 5 Kawakami H, Kuwatani M, Sakamoto N. Endoscopic ultrasound-guided antegrade diathermic dilation followed by self-expandable metallic stent placement for anastomotic stricture after hepaticojejunostomy (with video). Dig Endosc 2014; 26: 121-122