In the management of biliary stones, transpapillary stone extraction during endoscopic retrograde cholangiopancreatography (ERCP) has been established as the standard treatment [1]. The procedure is occasionally difficult, especially in cases with benign stricture of the duodenum caused by groove pancreatitis [2]. Stone extraction under percutaneous transhepatic biliary drainage and surgery are conventionally performed as alternative methods after unsuccessful ERCP [3]. However, both methods are invasive and reduce patients’ quality of life. Here, we present a successful case of biliary stone extraction achieved via creation of a neo papilla ([Video 1]).
Video 1 An alternative method after failed transpapillary stone extraction: a neo papilla was created by an endoscopic ultrasound-guided choledochoduodenostomy, followed by stone extraction via the newly created neo papilla.
A 78-year-old man underwent gastrojejunostomy for the duodenal stricture associated with groove pancreatitis and later developed obstructive jaundice due to biliary stone ([Fig. 1]). An attempted ERCP failed due to an inaccessible papilla. A neo papilla was created at the duodenal bulb by endoscopic ultrasound-guided choledochoduodenostomy with plastic stent placement to decompress the bile duct ([Fig. 2]). Biliary stone extraction was then attempted 1 month later via the neo papilla. The plastic stent was removed using a stent retriever (Soehendra Stent Retriever; Cook Medical, Bloomington, Indiana, USA) and a cholangiogram confirmed the existence of the stone. The neo papilla was dilated up to 8 mm using a balloon catheter (ZARA; Century Medical, Tokyo, Japan) ([Fig. 3]). The stones were then crushed using a mechanical lithotripter (XEMEX Crusher Catheter; Zeon Medical, Tokyo, Japan), and stone fragments were successfully removed though the neo papilla ([Fig. 4], [Fig. 5]). A nasobiliary drainage tube was then placed in the bile duct to wash away the small residual stone fragments. No adverse events occurred for the patient.
Fig. 1 Magnetic resonance imaging showed a stone in the common bile duct.
Fig. 2 Endoscopic ultrasound-guided choledochoduodenostomy was performed with plastic stent placement to decompress the bile duct.
Fig. 3 The neo papilla was dilated using a balloon catheter.
Fig. 4 The larger stones were crushed using the mechanical lithotripter.
Fig. 5 Stone fragments were successfully removed though the neo papilla.
Extraction of biliary stones via a created neo papilla appears to be safe and achievable, because the matured fistula allowed the use of larger devices [4]. This technique may be a feasible alternative to rescue transpapillary stone extraction in patients with benign stricture of the duodenum.
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Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
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