Peroral cholangioscopy-guided basket extraction of intrahepatic bile duct stones, using a novel thin cholangioscope under balloon enteroscopy, in a patient with Roux-en-Y anatomy

Endoscopic stone extraction using a balloon enteroscope in patients with a Roux-en-Y anastomosis is challenging due to the difficulty in aligning the axis between retrieval devices and stones, which often results in failure of stone capture [1] [2]. Recently, it has been reported that a novel thin cholangioscope (EyeMax; Micro-Tech, China), with a length of 219 cm and a diameter of 9 Fr, enables peroral cholangioscopy (POCS)-guided procedures using a balloon enteroscope with a 3.2-mm forceps channel ([Fig. 1]) [3] [4]. Furthermore, it also enables POCS-guided basket extraction. We report a case of successful POCS-guided basket extraction of intrahepatic bile duct stones using a novel thin cholangioscope under balloon enteroscopy in a patient who had undergone a Roux-en-Y procedure.

Fig. 1 Thin cholangioscope (EyeMax; Micro-Tech, China), length 219 cm, diameter 9 Fr.

A 68-year-old woman who had undergone hepaticojejunostomy with Roux-en-Y construction was referred to us. Computed tomography revealed stones in the intrahepatic bile duct ([Fig. 2]). Although the previous hospital had attempted stone extraction, the stones could not be captured using the basket catheter. Therefore, we performed endoscopic retrograde cholangiopancreatography (ERCP) using a short-type single-balloon enteroscope (SIF-H290; Olympus, Japan) with a working length of 152 cm and a working channel of diameter 3.2 mm [1] ([Video 1]). Cholangiography revealed stones in the intrahepatic bile duct ([Fig. 3]). Subsequently, POCS was performed using a thin cholangioscope, revealing stones in the intrahepatic bile duct ([Fig. 4]). Since the stones were considered difficult to capture, POCS-guided basket extraction was attempted using a retrieval basket (SpyGlass Retrieval Basket; Boston Scientific, USA) ([Fig. 5] a), that could be inserted through the thin cholangioscope. The stones were successfully captured under cholangioscopic visualization ([Fig. 5] b, c). Finally, complete stone extraction was confirmed using the cholangioscope ([Fig. 5] d).

Fig. 2 Computed tomography revealed stones (arrows) in the intrahepatic bile duct.

Fig. 3 Cholangiography revealed stones (arrows) in the intrahepatic bile duct.

Fig. 4 Cholangioscopic view of stones in the intrahepatic bile duct.

Fig. 5 Cholangioscopic and endoscopic findings. a Retrieval basket (SpyGlass Retrieval Basket; Boston Scientific, USA) that could be inserted through the thin cholangioscope. b, c The stones were successfully captured under cholangioscopic visualization. d Complete stone extraction was confirmed using the cholangioscope.

Peroral cholangioscopy-guided basket extraction of intrahepatic bile duct stones, using a novel thin cholangioscope under balloon enteroscopy, in a patient with Roux-en-Y anatomy.Video 1

POCS-guided basket extraction is beneficial for capturing difficult stones, as POCS allows for direct visualization of stones [5]. This thin cholangioscope enables POCS-guided basket extraction under balloon enteroscopy in patients with Roux-en-Y anatomy.

Endoscopy_UCTN_Code_TTT_1AR_2AH

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Tanisaka Y, Ryozawa S, Itoi T. et al. Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in Japan. Gastrointest Endosc 2022; 95: 310-318 e1
• 2 Tanisaka Y, Mizuide M, Fujita A. et al. Factors affecting complete stone extraction in the initial procedure in short type single-balloon enteroscopy-assisted endoscopic retrograde cholangiography for patients with Roux-en-Y gastrectomy. Scand J Gastroenterol 2022; 57: 1390-1396
• 3 Tanisaka Y, Mizuide M, Fujita A. et al. Successful cholangioscopy-guided biopsy using a novel thin cholangioscope under balloon enteroscopy in a patient with Roux-en-Y gastrectomy. Endoscopy 2024; 56: E256-E257
• 4 Tanisaka Y, Mizuide M, Fujita A. et al. Peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis. Endoscopy 2024; 56: E360-E361
• 5 Burlen J, Amaral AC, Hussain WK. et al. Cholangioscopy-directed basket extraction of bile duct stones in a pregnant patient. Endoscopy 2023; 55: E906-E907

Publication History

Article published online:
28 January 2025