A 35-year-old woman underwent a Roux-en-Y hepaticojejunostomy in 2001 for a bile duct
injury that occurred during a cholecystectomy for cholelithiasis. After the surgery,
she began to experience episodes of relapsing cholangitis, approximately once a year,
which were treated with antibiotics. However, from 2012 onwards, the episodes of cholangitis
increased in frequency to five or six episodes per year, including some episodes that
required prolonged hospitalization of up to 2 months. In 2014 she was referred to
our hospital, where she was found to have clinical evidence of chronic liver disease
that was classified as secondary biliary cirrhosis, and magnetic resonance cholangiopancreatography
(MRCP) revealed multiple left intrahepatic stones ([Fig. 1]).
Fig. 1 Magnetic resonance cholangiopancreatography (MRCP) image showing a left intrahepatic
stone (arrow).
Endoscopic retrograde cholangiopancreatography (ERCP) was not attempted by enteroscopy
because of the lack of the necessary device and accessories. The patient was not a
candidate for left hepatectomy because of chronic liver disease, so she was placed
on a waiting list for liver transplantation.
Because of the persistence of her cholangitis, we decided to attempt percutaneous
cholangioscopy with the single-operator direct-visualization SpyGlass system (Boston
Scientific Inc., Natick, Massachusetts, USA) and laser application. Initially, a percutaneous
8-Fr catheter was placed radiologically to access the left bile duct ([Fig. 2]). After 3 weeks, the SpyGlass system was used and laser lithotripsy was applied
([Fig. 3]; [Video 1]), with the stone fragments being removed in an antegrade fashion using the balloon
of a biliary extraction catheter (Cook Medical, Inc., Winston Salem, North Carolina,
USA).
Fig. 2 View during percutaneous cholangiography showing an intrahepatic stone.
Fig. 3 Radiographic images showing: a cholangiography being performed with the SpyGlass system; b the SpyGlass in position in the left intrahepatic duct during laser application;
c no evidence of intrahepatic lithiasis following laser lithotripsy and extraction
of the stone fragments.
Percutaneous cholangioscopy with the single-operator direct-visualization SpyGlass
system and application of laser lithotripsy.
On follow-up MRCP, no evidence of intrahepatic stones was observed ([Fig. 4]). The clinical outcome was successful, and the patient has had no new episodes of
cholangitis in 10 months of follow-up.
Fig. 4 Follow-up magnetic resonance cholangiopancreatography (MRCP) image showing no evidence
of intrahepatic lithiasis (arrow in the site where lithiasis was previously observed).
Surgery has traditionally been considered the best option for intrahepatic stones
[1]. Although enteroscopy-assisted access is an acceptable option to treat intrahepatic
cholelithiasis, lack of equipment may preclude this option. Percutaneous cholangioscopy
is also an acceptable option, especially in the presence of difficult intrahepatic
stones or distal bile duct stenosis [2]. Other access options have included transgastric and percutaneous transhepatic rendezvous
maneuvers [3].
To the best of our knowledge, this is the first report of percutaneous cholangioscopy
using SpyGlass with direct laser application (without the rendezvous technique) in
a patient with complex intrahepatic stones and a history of recurrent cholangitis
and chronic liver disease.
Endoscopy_UCTN_Code_TTT_1AR_2AJ
