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Electrohydraulic lithotripsy under the mother-baby cholangioscope system using a colonoscope for large common bile duct stones in a patient with Roux-en-Y reconstruction
After insertion of the cholangioscope into the common bile duct, electrohydraulic lithotripsy was performed. All common bile duct stones were shattered and successfully removed using a basket and balloon catheter.
Electrohydraulic lithotripsy (EHL) is useful for the treatment of common bile duct (CBD) stones (CBDSs) when stones are larger than 2 cm in diameter or conventional extraction methods have proven ineffective.
However, EHL requires direct visualization of the CBD, which is often challenging in patients who have undergone Roux-en-Y reconstruction. There have been some reports of EHL under direct cholangioscopy using an enteroscope or ultra-slim upper endoscope for patients with a history of Roux-en-Y reconstruction.
Electrohydraulic lithotripsy under double-balloon endoscope-assisted direct cholangioscopy for treatment of choledocholithiasis in a patient with Roux-en-Y gastrectomy.
Electrohydraulic lithotripsy under peroral direct cholangioscopy using short-type single-balloon enteroscope for large common bile duct stone in patients with Roux-en-Y gastrectomy.
However, when the distal CBD is narrow or the main papilla is oriented vertically toward the intestine, it is difficult to insert the endoscope as described in previous reports. This report describes a case in which EHL was performed using a mother-baby cholangioscope system and a colonoscope for a patient who had previously undergone Roux-en-Y reconstruction.
An 80-year-old man who regularly attended a hospital for cirrhosis due to hepatitis C virus infection visited our hospital with abdominal pain. The patient had a history of radiofrequency ablation (RFA) for hepatocellular carcinoma in S8 and Roux-en-Y reconstruction for a gastric ulcer. He was diagnosed with cholangitis due to CBDSs (Fig. 1).
Figure 1CT shows several common bile duct stones in the dilated extrahepatic bile duct (arrow). The patient’s scar from radiofrequency ablation for hepatocellular carcinoma was detected in S8 (arrowhead).
Endoscopic retrograde cholangiography was planned using a short-type, double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan). However, the main papilla was oriented vertically toward the intestine, and the catheter could not be inserted into the CBD. The patient needed biliary drainage to treat the cholangitis; therefore, percutaneous transhepatic biliary drainage (PTBD) was performed on the right side of the intrahepatic bile duct during the same procedure. Because the patient had severe cirrhosis and the RFA scar in S8, he was considered to have a risk of developing a biloma in this scar with stone removal using the PTBD route. Therefore, we retried transpapillary stone removal after 1 week.
In the second session, the catheter was inserted into the CBD using the PTBD-rendezvous technique (Fig. 2). Endoscopic papillary large balloon dilation using a 15-mm-diameter balloon (13-15 mm REN; Kaneka, Osaka, Japan) was subsequently performed. The CBDSs were removed using mechanical lithotripsy and a balloon catheter (Trapezoid and Extractor Pro RX; Boston Scientific, Marlborough, Mass, USA). However, there was no space to deploy the basket catheter because the large CBDSs were obstructing the CBD and the distal CBD was narrow (≤ 8 mm). Therefore, we could not capture and remove all the CBDSs with this method (Fig. 3). EHL (Autolith Touch; Boston Scientific) under cholangioscopy was needed for the removal of the CBDSs, and we tried to insert the enteroscope into the CBD. However, the distal CBD was narrow and the main papilla was oriented vertically, which prevented insertion of the enteroscope into the CBD.
Figure 2A, The main papilla was oriented vertically toward the intestine; as such, we could not insert the endoscope into the common bile duct (CBD) during the first session. B, After percutaneous transhepatic biliary drainage placement, we could access the CBD using the percutaneous transhepatic biliary drainage-rendezvous technique. However, we discovered that the CBD was clogged with large CBD stones.
Figure 3Because the common bile duct (CBD) was clogged with large stones, there was no space to deploy the basket catheter. The narrow distal CBD (≤8 mm, arrowhead) prevented insertion of the enteroscope into the CBD.
To pass through the narrow CBD while accounting for the vertical insertion, we considered the use of a cholangioscope (Spyglass DS, outer diameter 3.0 mm, working length 2150 mm; Boston Scientific) with a mother-baby system. In the third session, we used a colonoscope with a 3.7-mm-diameter working channel (CF-HQ290I, working length 1330 mm; Olympus, Tokyo, Japan) to insert the cholangioscope into the CBD. After the colonoscope reached the main papilla, which was already dilated from the previous procedure, the cannula was smoothly inserted into the CBD. The guidewire was then inserted into the CBD and used to guide cholangioscope insertion through the colonoscope into the CBD. EHL was then performed under cholangioscopy (Video 1, available online at www.giejournal.org), and all of the CBDSs were successfully removed using a basket and balloon catheter (Fig. 4). No adverse events (AEs) occurred after the procedure.
Figure 4A, The cholangioscope (Spyglass DS) was successfully inserted into the common bile duct (CBD) under wire guidance through the colonoscope. CBD stones were then directly detectable by cholangioscopy. B, The CBD stones were shattered by electrohydraulic lithotripsy and subsequently removed using a basket and balloon catheter.
We successfully performed EHL under cholangioscopy through a colonoscope in a patient with a history of Roux-en-Y reconstruction and RFA, without AEs. A native papilla has been reported to be a risk factor for AEs, including post-ERCP pancreatitis, in balloon enteroscopy–assisted ERCP in patients with a history of Roux-en-Y reconstruction.
Evaluation of complications after endoscopic retrogradecholangiopancreatography using a short type double balloonendoscope in patients with altered gastrointestinal anatomy: asingle-center retrospective study of 1,576 procedures.
The risk of AEs was reduced in this case by using the PTBD-rendezvous technique to facilitate cannulation and by dividing the endoscopic retrograde cholangiography procedures into 2 separate sessions, which reduced the treatment time of each session. As such, when a colonoscope can reach the main papilla in patients with a history of Roux-en-Y reconstruction, a mother-baby cholangioscope system may be an option for resolving challenging CBDSs.
After insertion of the cholangioscope into the common bile duct, electrohydraulic lithotripsy was performed. All common bile duct stones were shattered and successfully removed using a basket and balloon catheter.
References
Binmoeller K.F.
Brückner M.
Thonke F.
et al.
Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy.
Electrohydraulic lithotripsy under double-balloon endoscope-assisted direct cholangioscopy for treatment of choledocholithiasis in a patient with Roux-en-Y gastrectomy.
Electrohydraulic lithotripsy under peroral direct cholangioscopy using short-type single-balloon enteroscope for large common bile duct stone in patients with Roux-en-Y gastrectomy.
Evaluation of complications after endoscopic retrogradecholangiopancreatography using a short type double balloonendoscope in patients with altered gastrointestinal anatomy: asingle-center retrospective study of 1,576 procedures.
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