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

Although balloon enteroscopy is helpful, stone extraction in patients with Roux-en-Y anastomosis can be very difficult, particularly in cases with multiple large stones [1] [2]. Recently, a thin cholangioscope (eyeMAX; Micro-Tech, China) with a length of 219 cm and a diameter of 9-Fr ([Fig. 1]) has enabled peroral cholangioscopy (POCS)-guided interventions to be performed under balloon enteroscopy [3]. POCS-guided intraductal interventions using either laser lithotripsy or electrohydraulic lithotripsy (EHL) can facilitate the extraction of difficult stones [4] [5]. It has been reported that, compared with EHL, laser lithotripsy provides the advantage of more precise stone targeting, thereby reducing the risk of injury to the surrounding tissue [3]. We report a case of successful laser lithotripsy using a thin cholangioscope under balloon enteroscopy in a patient with Roux-en-Y anastomosis.

Fig. 1 A thin cholangioscope (eyeMAX; Micro-Tech, China) measuring 219 cm in length, with a diameter of 9-Fr.

A 61-year-old woman with multiple large stones in the right intrahepatic bile duct, who had previously undergone hepaticojejunostomy with Roux-en-Y, was referred to us ([Fig. 2]). Endoscopic retrograde cholangiopancreatography was performed using a short-type single-balloon enteroscopy (SIF-H290; Olympus Marketing, Japan) with a working length of 152 cm and a working channel of 3.2 mm in diameter ([Video 1] [1] [2]). Cholangiography revealed multiple large stones in the right intrahepatic bile duct ([Fig. 3]). Subsequently, POCS was performed using a thin cholangioscope and revealed multiple large stones in the intrahepatic bile duct ([Fig. 4] a). A laser fiber was introduced, and POCS-guided laser lithotripsy was performed under a clear field of view. Precise targeting and fragmentation of the stones were achieved safely ([Fig. 4] b,c), resulting in complete stone extraction ([Fig. 5]).

Fig. 2 Magnetic resonance imaging revealing multiple large stones in the right intrahepatic bile duct (red arrow).

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Peroral cholangioscopy-guided laser lithotripsy using a thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis.Video 1

Fig. 3 Cholangiography revealing multiple large stones in the right intrahepatic bile duct (red arrow).

Fig. 4 Cholangioscopy findings. a Cholangioscopy revealing multiple large stones in the right intrahepatic bile duct. b, c Precise targeting and fragmentation of the stones were achieved safely.

Fig. 5 Endoscopic findings revealing successful complete stone extraction.

This case highlights the utility of POCS-guided laser lithotripsy using a thin cholangioscope, even in the setting of balloon enteroscopy. Both the thin cholangioscope and the laser fiber can improve the success rate of stone extraction in such patients.

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Contributorsʼ Statement

Yuki Tanisaka: Conceptualization, Investigation, Writing – original draft, Writing – review & editing. Shomei Ryozawa: Supervision, Writing – review & editing. Masafumi Mizuide: Supervision, Writing – review & editing. Akashi Fujita: Investigation, Writing – review & editing. Ryuichi Watanabe: Investigation, Writing – review & editing. Ryosuke Hamamura: Investigation, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• 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 Tanisaka Y, Ryozawa S, Mizuide M. et al. Cholangioscopy-guided guidewire insertion into the gallbladder using a novel thin cholangioscope under balloon enteroscopy in a patient with Roux-en-Y gastrectomy. Endoscopy 2025; 57: E1023-E1024
• 4 Veld JV, van Huijgevoort NCM, Boermeester MA. et al. A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave. Endoscopy 2018; 50: 896-909
• 5 McCarty TR, Gulati R, Rustagi T. Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: a systematic review and meta-analysis. Endoscopy 2021; 53: 110-122

Publication History

Article published online:
19 November 2025