Endoscopy 2016; 48(S 01): E146-E147
DOI: 10.1055/s-0042-105561
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Peroral transhepatic cholangioscopy-guided electrohydraulic lithotripsy via an endoscopic ultrasonography-guided hepaticogastrostomy route for bile duct stones in a patient with Roux-en-Y anatomy

Hiroshi Kawakami
1   Department of Gastroenterology and Hepatology, Center for Digestive Disease, The University of Miyazaki, Miyazaki, Japan
2   Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
,
Yoshimasa Kubota
1   Department of Gastroenterology and Hepatology, Center for Digestive Disease, The University of Miyazaki, Miyazaki, Japan
2   Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
,
Shuhei Kawahata
2   Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
,
Kimitoshi Kubo
2   Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
,
Shinji Okabayashi
3   Gastroenterology Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
,
Ryoji Tatsumi
3   Gastroenterology Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
,
Naoya Sakamoto
2   Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan
4   Department of Gastroenterology and Hepatology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
26 April 2016 (online)

Endoscopic ultrasonography (EUS)-guided antegrade bile duct stone treatment has been developed for patients with altered anatomy [1] [2] [3] [4] [5]. Here, we present a case of successful bile duct stone treatment via an EUS-guided hepaticogastrostomy (EUS-HGS) route in the setting of prior Roux-en-Y reconstruction. Direct peroral transhepatic cholangioscopy-guided electronic hydraulic lithotripsy (EHL) and endoscopic papillary large-balloon dilation (EPLBD) were used.

An 84-year-old man with bile duct stones, acute cholecystitis, cholangitis, and a history of distal gastrectomy with Roux-en-Y reconstruction was referred to our hospital. As the papilla was inaccessible even with balloon enteroscopy, only percutaneous transhepatic gallbladder drainage had been previously performed.

Transhepatic EUS-guided antegrade treatment was selected for the treatment of the bile duct stones. A B3 branch duct was punctured using a 22-gauge needle, and a 0.018-inch guidewire (NovaGold; Boston Scientific Japan, Tokyo, Japan) was placed. EUS-guided antegrade cholangiography revealed multiple bile duct stones ([Fig. 1 a]). After exchanging to a 0.035-inch guidewire (Jagwire Plus High Performance Guidewire; Boston Scientific), we performed EPLBD (Giga, 13 – 15 mm; Century Medical, Tokyo, Japan) under fluoroscopic guidance ([Fig. 1 b]), but were unable to extract the bile duct stones using a retrieval balloon (Extractor Pro RX retrieval balloon catheter, 15 – 18 mm; Boston Scientific) ([Video 1]). A partially covered self-expandable metallic stent (WallFlex, 10 × 60 mm, Boston) was placed without complications ([Fig. 1 c]).

Zoom Image
Fig. 1 Transhepatic endosonography (EUS)-guided antegrade approach for attempted treatment of bile duct stones in an 84-year-old man with Roux-en-Y anatomy: radiographic views. a Multiple bile duct stones (arrows). b EUS-guided papillary balloon dilation under fluoroscopic guidance. The bile duct stones could not be extracted. c A self-expandable metallic stent was placed via the EUS-guided hepaticogastrostomy route. Inset: endoscopic image.


Quality:
Attempted treatment of bile duct stones in an 84-year-old man with Roux-en-Y anatomy: bile duct puncture and antegrade cholangiography under endoscopic ultrasonography (EUS) and fluoroscopic guidance; guidewire insertion into the intrahepatic bile duct and advancement towards the distal bile duct under fluoroscopic guidance; endoscopic papillary large-balloon dilation (EPLBD) under fluoroscopic guidance; and failure of stone extraction using the balloon catheter.

Then 1 month later, we performed EHL under direct antegrade peroral video cholangioscopy (SpyGlass DS; Boston Scientific) using a therapeutic duodenoscope via an EUS-HGS route ([Fig. 2], [Video 2]). However, extraction of the bile duct stones, this time by basket and balloon catheter, again failed. Therefore, 2 months later, we repeated EPLBD, and achieved complete clearance of the bile duct stones with a balloon catheter ([Fig. 3]).

Zoom Image
Fig. 2 At 1 month later, the radiograph shows direct peroral transhepatic cholangioscopy with electrohydraulic lithotripsy through the endoscopic ultrasound-guided hepaticogastrostomy route. Extraction of the bile duct stones again failed. Inset: endoscopic image.


Quality:
At 1 month later, direct peroral transhepatic cholangioscopy-guided electronic hydraulic lithotripsy via an endoscopic ultrasound-guided hepaticogastrostomy route.

Zoom Image
Fig. 3 At 2 months later: the radiograph shows complete clearance of bile duct stones by means of endoscopic papillary large-balloon dilation (EPLBD). The arrow shows a bile duct stone in the duodenal lumen.

Although it is challenging, EUS-guided antegrade cholangiography and cholangioscopy (EUS-ACC) should be recognized as a treatment in patients with altered gastrointestinal anatomy. We have recently reported successful EUS-ACC in one such case [4]. Tonozuka et al. have described laser lithotripsy via the EUS-HGS route after pancreaticoduodenectomy [5]. To our knowledge, this is the first report of treatment for bile duct stones with EHL via an EUS-HGS route guided by direct antegrade cholangioscopy.

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