A case of complete removal of stacked common bile duct stones by peroral direct digital cholangioscopy in a patient with surgically altered anatomy

Treatment of common bile duct stones or anastomotic stenosis is challenging in patients with surgically altered anatomy (SAA). Although the clinical outcomes of balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) have been improving in these patients,1-3 stacked stones are still difficult to remove in some cases. There are also cases in which electrohydraulic lithotripsy (EHL) is required for the removal of stacked stones in patients with SAA.4 The patient in this case was an 89-year-old man who had undergone Roux-en Y reconstruction after resection of gastric cancer. He was admitted to our hospital for treatment of cholangitis due to stacked common bile duct stones. BE-ERCP was attempted for bile duct drainage, but the papilla could not be identified and percutaneous transhepatic biliary drainage was performed. Then rendezvous BE-ERCP using the percutaneous transhepatic drainage route was performed (Figure 1). Although the papilla could be identified, the stacked stones were difficult to remove, and EHL was planned for the next session. Unfortunately, a peroral direct digital cholangioscope (SpyDS; Boston Scientific, Natick, Massachusetts, USA) with a caliber of 3.3 mm was not available for BE-ERCP because of the limited diameter of the accessory channel (3.2 mm). Therefore, ERCP was performed using a colonoscope (CF-XZ1200; Olympus Medical, Tokyo, Japan), in which the cholangioscope can be inserted via the accessory channel (3.7 mm). The cholangioscope was inserted into the common bile duct via the CF-XZ1200 and showed that the common bile duct was filled with stacked stones. The stacked stones were crushed by EHL and cholangiography showed that the stones were reduced in size. The stones were completely removed using a mechanical lithotripter and basket catheter. The patient had a favorable course and was discharged (Figure 2). This case demonstrates that stacked stones can be safely and effectively removed by EHL and other tools with the CF-XZ1200 in a patient with SAA. Conception and design: Noriyuki Hirakawa, Katsuya Kitamura and Takao Itoi. Manuscript preparation: Noriyuki Hirakawa. Endoscopic procedures: Noriyuki Hirakawa and Katsuya Kitamura. Video S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.