A case of severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction treated by endoscopic ultrasound-guided transhepatic antegrade stone removal

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (ERCP) is useful for the treatment of bile duct stones in patients with surgically altered anatomy [1] [2] [3]; however, the procedure cannot always successfully remove stones when the anastomotic site or papilla of Vater cannot be reached. Recently, endoscopic ultrasound (EUS)-guided antegrade intervention has been developed for benign biliary diseases, including hepatolithiasis in patients with altered anatomy [4] [5]. We report a case of EUS-guided transhepatic antegrade stone removal (EUS-TASR) in a patient with altered anatomy ([Video 1]).

Video 1 Endoscopic ultrasound-guided transhepatic antegrade stone removal was useful for severe hepatolithiasis after hepaticojejunostomy with Roux-en-Y reconstruction.

The 59-year-old man underwent hepaticojejunostomy with Roux-en-Y reconstruction for hepatolithiasis several years previously. He was referred to our hospital for treatment of severe hepatolithiasis. Abdominal computed tomography showed huge impacted stones in the hilum and a dilated left intrahepatic bile duct ([Fig. 1 a] ).

Fig. 1 Computed tomography. a Before treatment, showing huge impacted stones in the hilum and a dilated left intrahepatic bile duct. b After the procedure, showing complete clearance.

We chose to perform EUS-TASR because accessing the anastomotic site by balloon-assisted ERCP was judged to be difficult owing to the long afferent loop and because multiple sessions would be required for stone removal.

We first performed EUS-guided hepaticogastrostomy (EUS-HGS). The dilated left intrahepatic bile duct was punctured using a 19-gauge fine-needle aspiration needle from the residual stomach side. Cholangiography showed multiple impacted stones from the hilum to the bilateral intrahepatic bile ducts. A 0.025-inch guidewire was inserted into the intrahepatic bile duct and the needle tract was dilated using an ultra-tapered mechanical dilator. A fully covered metal stent was then placed over the guidewire ([Fig. 2]).

Fig. 2 Endoscopic ultrasound-guided hepaticogastrostomy.

EUS-TASR was performed 1 month later. After dilation of the anastomotic stricture using a balloon catheter, a cholangioscope was inserted into the intrahepatic bile duct through the metal stent. Bile duct stones were crushed using electrohydraulic lithotripsy under direct visualization ([Fig. 3]). Subsequently, stone fragments were removed using a basket catheter and balloon catheter through the anastomotic route and HGS route ([Fig. 4]). Finally, the huge hepatic bile duct stone was completely removed ([Fig. 1 b]).

Fig. 3 Bile duct stones were crushed using electrohydraulic lithotripsy under direct visualization.

Fig. 4 Stone fragments were removed using a basket catheter through the hepaticogastrostomy route under direct visualization.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Itoi T, Ishii K, Sofuni A. et al. Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc 2011; 25: 713-721
• 2 Itokawa F, Itoi T, Ishii K. et al. Single- and double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y plus hepaticojejunostomy anastomosis and Whipple resection. Dig Endosc 2014; 26: 136-143
• 3 Ishii K, Itoi T, Tonozuka R. et al. Balloon enteroscopy-assisted ERCP in patients with Roux-en-Y gastrectomy and intact papillae (with videos). Gastrointest Endosc 2016; 83: 377-386
• 4 Itoi T, Sofuni A, Tsuchiya T. et al. Endoscopic ultrasonography-guided transhepatic antegrade stone removal in patients with surgically altered anatomy: case series and technical review (with videos). J Hepatobiliary Pancreat Sci 2014; 21: E86-E93
• 5 Mukai S, Itoi T, Sofuni A. et al. EUS-guided antegrade intervention for benign biliary diseases in patients with surgically altered anatomy (with videos). Gastrointest Endosc 2019; 89: 399-407

Publication History

Article published online:
23 September 2020