Peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis

Stone extraction using endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than surgical procedures. However, stone extraction in patients with surgically altered anatomy, such as those who have undergone a Roux-en-Y procedure, is challenging. Although balloon enteroscopy is useful for such cases, there is still room for improvement [1] [2]. Peroral cholangioscopy (POCS)-guided lithotripsy can aid in the extraction of stones that are difficult to remove [3] [4]. However, performing POCS-guided lithotripsy under balloon enteroscopy is difficult because cholangioscopes have an approximate diameter of 10 Fr and cannot pass through the forceps channel of the balloon enteroscope. This report describes a patient with a Roux-en-Y anastomosis who was successfully treated with POCS-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy.

A 51-year-old woman who had previously undergone a diversion operation and hepaticojejunostomy with Roux-en-Y for congenital biliary dilatation 7 years earlier was referred to our center. Computed tomography revealed large stones in the intrahepatic bile duct ([Fig. 1]). Consequently, we performed ERCP using a short-type single-balloon enteroscope (SIF-H290; Olympus, Tokyo, Japan) with a working length of 152 cm and a working channel with a diameter of 3.2 mm [1] [2]. Additionally, we performed POCS-guided lithotripsy using a thin cholangioscope (eyeMAX; Micro-Tech, Nanjing, China) with a length of 219 cm and diameter of 9 Fr [5] ([Fig. 2] , [Video 1]) as complete stone extraction was difficult without POCS. Cholangiography revealed large stones in the intrahepatic bile duct ([Fig. 3]). Subsequently, POCS was performed using a thin cholangioscope, revealing multiple large stones in the intrahepatic bile duct ([Fig. 4] a). POCS-guided lithotripsy was performed while maintaining a clear field of view ([Fig. 4] b, c). Successful stone fragmentation was achieved ([Fig. 4] d), followed by complete stone extraction ([Fig. 5]).

Fig. 1 Computed tomography revealed large stones (red arrows) in the intrahepatic bile duct.

Fig. 2 Thin cholangioscope (eyeMAX; Micro-Tech, Nanjing, China) with a length of 219 cm and diameter of 9 Fr.

Fig. 3 Cholangiography revealed large stones (red arrows) in the intrahepatic bile duct.

Fig. 4 Cholangioscopy findings. a Cholangioscopy revealed multiple large stones in the intrahepatic bile duct. b,c Peroral cholangioscopy-guided lithotripsy is performed while maintaining a clear field of view. d Stone fragmentation has been successfully achieved.

Fig. 5 Endoscopy revealed successful stone extraction.

Successful peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy in a patient who had previously undergone a Roux-en-Y procedure.Video 1

The thin cholangioscope was effective for POCS-guided lithotripsy even though a balloon enteroscope was used. This novel thin cholangioscope can improve the success rate of stone extraction in patients with a surgically altered anatomy.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We thank Editage (www.editage.com) for English language editing.

• References

• 1 Tanisaka Y, Ryozawa S, Itoi T. et al. Efficacy and factors affecting procedure results of short-type single-balloon enteroscopy-assisted ERCP for altered anatomy: a multicenter cohort in Japan. Gastrointest Endosc 2022; 95: 310-318.e1
• 2 Tanisaka Y, Mizuide M, Fujita A. et al. Factors affecting complete stone extraction in the initial procedure in short type single-balloon enteroscopy-assisted endoscopic retrograde cholangiography for patients with Roux-en-Y gastrectomy. Scand J Gastroenterol 2022; 57: 1390-1396
• 3 Maydeo AP, Rerknimitr R, Lau JY. et al. Cholangioscopy-guided lithotripsy for difficult bile duct stone clearance in a single session of ERCP: results from a large multinational registry demonstrate high success rates. Endoscopy 2019; 51: 922-929
• 4 Angsuwatcharakon P, Kulpatcharapong S, Ridtitid W. et al. Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study. Endoscopy 2019; 51: 1066-1073
• 5 Liu WH, Huang XY, Hu X. et al. Initial experience of visualized biliary cannulation during ERCP. Endoscopy 2023; 55: 1037-1042

Publikationsverlauf

Artikel online veröffentlicht:
24. April 2024