Peroral intraductal cholangioscopy-guided laser lithotripsy via endoscopic ultrasound-guided hepaticogastrostomy for intrahepatic bile duct lithiasis

 

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A 25-year-old man was referred for recurrent cholangitis. At the age of 5, he had undergone surgery for a Todani Type 1 choledochal cyst, with a Roux-en-Y hepaticojejunostomy reconstruction. He experienced several bouts of cholangitis in 2016. Magnetic resonance cholangiopancreatography (MRCP) showed dilated intrahepatic ducts, with bile duct stones in the right posterior sector and above a stenosis at the hepaticojejunal anastomosis ([Video 1]).

Video 1 Peroral intraductal cholangioscopy-guided laser lithotripsy through an endoscopic ultrasound-guided hepaticogastrostomy route for intrahepatic bile duct lithiasis.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) was performed using a curved linear array echoendoscope. Access to the left hepatic ducts was obtained from the proximal gastric cardia using a 19-gauge access needle. The cholangiogram showed a stricture of the anastomosis with stones above it, free-draining left and right anterior ducts, and obstructed right posterior ducts. The needle tract was coagulated before a large fully covered self-expandable metal stent (FCSEMS; 8-cm long, 10-mm diameter) was inserted into the left hepatic duct. A hydrostatic macrodilation (to 15 mm in diameter) of the anastomosis was performed ([Fig. 1]) and stones at the main confluence were pushed downwards into the jejunal limb ([Video 1]).

Direct antegrade peroral video cholangioscopy (SpyGlass DS; Boston Scientific) was performed 2 weeks later through the HGS after hydrostatic dilation to 8 mm. Cholangioscopic exploration of the biliary tract confirmed complete stone obstruction of the right posterior biliary tract. Laser lithotripsy was performed (1200 mJ, 4 Hz; Holmium, Auriga) and the stones were completely removed by fragmentation ([Fig. 2]).

The patient was discharged 24 hours after the procedure. The FCSEMS was removed 2 months later and a double pigtail stent (10 Fr × 15 cm) was left in position passing through the HGS for 12 months to maintain the patency of the hepaticogastric anastomosis. After the double pigtail stent had been removed, direct cholangiography using a balloon catheter ([Fig. 3]) and magnetic resonance imaging ([Fig. 4]) showed the absence of any residual stones and an entirely normal cholangiogram. The patient remained symptom free 1 year after this procedure.

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