Intrahepatic bile duct stone removal using a tapered-tip sheath system

A 64-year-old man with hilar biliary strictures following liver transplantation was admitted for a scheduled biliary stent exchange. During initial endoscopic retrograde cholangiopancreatography (ERCP), a filling defect on the peripheral side of the B6 branch stricture was observed ([Fig. 1] a, b), indicating intrahepatic bile duct (IHBD) stones. The stricture was dilated using a 6-mm dilation balloon catheter (REN; Kaneka Co., Inc.) ([Fig. 1] c), and 5 Fr endoscopic nasobiliary drainage tubes (SilkyPass J type, Boston Scientific Co.) were inserted. Stones were removed during the second ERCP session. A basket catheter (Medi-Globe 8-Wire Nitinol Basket; Medico’s Hirata Inc) was inserted over the guidewire (EndoSelector, Boston Scientific Co.) ([Fig. 2] a); however, not all of the stones were removed ([Fig. 2] b). A three-layered mechanical lithotripter (Xemex Crusher Catheter LBMT320; Zeon Medical) was used for the larger stones but failed to pass through the stricture ([Fig. 2] c). Therefore, a tapered tip sheath system (EndoSheather, Piolax), composed of a tapered inner catheter and an outer sheath ([Fig. 3] a, b), was advanced over the guidewire and positioned at the periphery of the remaining filling defects. The inner sheath and guidewire were withdrawn ([Fig. 4] a), and the three-layered inner basket of the lithotripter was inserted through the outer sheath ([Fig. 4] b). The remaining stones were captured ([Fig. 4] c), achieving complete stone removal ([Fig. 4] d, [Video 1]).

Fig. 1 The images of the initial endoscopic retrograde cholangiopancreatography (ERCP) procedure. A cholangiography image showing a filling defect (a yellow arrowheads) on the peripheral side of the B6 branch stricture (b yellow arrowheads). c The B6 branch stricture was dilated using a 6-mm dilation balloon catheter (REN; Kaneka Co., Inc.).

Fig. 2 The images of the second ERCP procedure. a A basket catheter (Medi-Globe 8-Wire Nitinol Basket; Medico Hirata Inc.) was inserted into the B6 branch. b Some stones were successfully removed using a basket catheter. c A three-layered mechanical lithotripsy basket (Xemex Crusher Catheter LBMT320; Zeon Medical) failed to pass through the stricture or angulation of the B6 branch.

Fig. 3 Images of the tapered-tip sheath system. a Overview of the tapered-tip sheath system (EndoSheather, Piolax). b The tapered-tip inner catheter tip (a yellow arrow) and an outer sheath (a white arrow). c Tip of the inner basket of the lithotripter (Xemex Crusher Catheter LBMT320; Zeon Medical) (a red arrow) and an outer sheath (a white arrow).

Fig. 4 Stone removal using the tapered-tip sheath system. a The tapered-tip sheath system was inserted over the guidewire to the peripheral side of the remaining filling defects. Thereafter, the inner sheath and the guidewire were withdrawn (white arrows). b The three-layered inner basket was inserted through the outer sheath. c The basket successfully recovered the remaining stones. d Complete removal of the B6 stones was achieved.

This video shows the efficient procedure for intrahepatic bile duct stone removal using a tapered-tip sheath system.Video 1

Biliary strictures are common complications of liver transplantation leading to IHBD stone formation distal to the stricture [1]. Endoscopic transpapillary stone removal can be challenging because of bile duct angulation and strictures [2]. The tapered-tip sheath system, originally developed for bile duct biopsy [3], enabled the deployment of the basket along the same axis as the bile duct, facilitating efficient stone retrieval and improving the efficiency of IHBD stone removal.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Boeva I, Karagyozov PI, Tishkov I. Post-liver transplant biliary complications: Current knowledge and therapeutic advances. World J. Hepatol 2021; 13: 66-79
• 2 Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25: 376-385
• 3 Matsumori T, Uza N, Shiokawa M. et al. Clinical impact of a novel device delivery system in the diagnosis of bile duct lesions: A single-center experience. J Gastroenterol Hepatol 2022; 37: 1360-1366

Publication History

Article published online:
18 June 2025