Implementing Therapeutic Endoscopic Retrograde Cholangiopancreatography in a Resource-Limited Setting: Lessons from the First Completely Minimally Invasive Management of Choledocholithiasis in Benin Republic

Background: Laparoscopic cholecystectomy combined with therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the reference minimally invasive treatment for common bile duct stones, but access remains limited in resource-constrained settings. We report the first completely minimally invasive management of choledocholithiasis achieved in Benin. Case Report: A 35-year-old man was referred for acute calculous cholecystitis with 3 months of recurrent right upper quadrant pain, fever, intermittent jaundice, dark urine, and pale stools. Investigation showed hyperbilirubinemia, cholestasis, modest cytolysis, and a coagulopathy corrected by parenteral vitamin K1. Ultrasonography showed multiple gallbladder calculi without a visible ductal stone. Laparoscopic cholecystectomy with transcystic drainage was performed; cholangiography through the drain on postoperative day 6 demonstrated three retained common bile duct stones. A laparoendoscopic rendezvous was planned, but the guidewire could not be advanced antegradely through the drain, and transpapillary salvage was undertaken. Guidewire-assisted cannulation, sphincterotomy, five basket passes, and balloon sweeping achieved complete clearance, confirmed by completion cholangiography. The procedure lasted 260 minutes. No adverse event occurred, and the patient remained asymptomatic at 8 years. Technical Considerations: Conservative case selection, correction of the coagulopathy before sphincterotomy, rehearsed multidisciplinary preparation, and predefined electrosurgical settings determined the safety of this inaugural procedure. Failure of the rendezvous was anticipated, and a transpapillary fallback was prepared in advance. Conclusion: Therapeutic ERCP can complete a fully minimally invasive biliary pathway in a resource-limited setting when introduced through careful case selection, appropriate training, multidisciplinary preparation, and standardized technique. The experience may inform centers developing advanced therapeutic endoscopy in similar settings.