A 68-year-old man with a history of Roux-en-Y partial gastrectomy for gastric cancer
and pancreatic enucleation for a somatostatin-producing neuroendocrine tumor underwent
urgent open cholecystectomy due to acute cholecystitis. Intraoperative choledochoscopy
showed a common bile duct (CBD) stone which could not be removed. A transcystic Nelaton
tube was placed. One week later, cholangiography confirmed the 10-mm CBD stone was
still present. The tube was left in place to allow maturation of the tract for a further
procedure, but 20 days later it was accidentally displaced. As percutaneous biliary
drainage persisted, the patient was referred to us to try percutaneous transcystic
cholangioscopy-guided electrohydraulic lithotripsy. Contrast instilled directly into
the percutaneous access confirmed persistence of the tract, which was tortuous and
narrowed in the proximal part ([Fig. 1]). Guidewire passage into the CBD was difficult ([Fig. 2]) and was only achieved under contrast guidance with looping of the guidewire and
single-operator cholangioscope (Spyglass DS II) assistance. Passage of the cholangioscope
into the CBD was possible after gentle dilatation of the proximal part of the tract,
and the stone was visualized in the distal part of the CBD ([Fig. 3]). Electrohydraulic lithotripsy was performed under direct visualization with pulverization
of the stone ([Fig. 4]; [Video 1]). A 10-Fr double-pigtail plastic stent was left in place for 24 h ([Fig. 5]) to ensure easy access to the CBD in case of any complications. The patient remains
well 1 month later.
Fig. 1 Fluoroscopic image confirming persistence of the percutaneous tract, which is tortuous
and narrowed in the proximal part.
Fig. 2 Cholangioscopic image of the percutaneous tract during access to the common bile
duct.
Fig. 3 Cholangioscopic image of the stone located in the distal part of the common bile
duct.
Fig. 4 Cholangioscopic image during electrohydraulic lithotripsy of the stone.
Video 1 Percutaneous transcystic cholangioscopy-guided electrohydraulic lithotripsy in a
patient with altered surgical anatomy.
Fig. 5 Fluoroscopic image after placement of the 10-Fr double-pigtail plastic stent.
Peroral endoscopic access to the biliary tree is difficult after surgical procedures
which alter the upper gastrointestinal anatomy. Although there have been previous
reports of percutaneous transhepatic cholangioscopy and lithotripsy [1]
[2], transcystic access is less frequent [3]. In 7 % of procedures, complications occur – mainly biliary sepsis, hemobilia, and
bile duct injuries [4]. Percutaneous tracts must be allowed to mature before they are used, in order to
reduce the risk of complications. Tract maturation time (4 days to 6 weeks) depends
on the diameter needed for biliary access.
Endoscopy_UCTN_Code_TTT_1AR_2AH
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