Electronic hydraulic lithotripsy by antegrade digital cholangioscopy through endoscopic ultrasound-guided hepaticojejunostomy
This report describes antegrade electronic hydraulic lithotripsy (Lithotron EL 27; Walz Elektronik, Rohrdorf, Germany) using a digital peroral cholangioscope (SpyGlass DS System; Boston Scientific, Marlborough, Massachusetts, USA)   through an endoscopic ultrasound (EUS)-guided hepaticojejunostomy route for common bile duct (CBD) stones ( [Video 1] ).
Video 1 Antegrade electronic hydraulic lithotripsy using a digital peroral cholangioscope through an endoscopic ultrasound-guided hepaticojejunostomy fistula. This novel method could become a rescue procedure when the conventional transpapillary approach is unsuccessful.
A 77-year-old man, who underwent total gastrectomy with a Roux-en-Y procedure for gastric cancer, presented with cholangitis caused by CBD stones. Endoscopic transpapillary drainage was attempted, but the scope could not be inserted into the ampulla; therefore, EUS-guided hepaticojejunostomy was performed.
From the Roux-en-Y jejunum, the dilated intrahepatic bile duct was punctured with a 19-gauge needle under EUS. After guidewire insertion toward the distal bile duct, the puncture site was dilated using a balloon dilator (diameter 4 mm, REN; Kaneka Medix, Osaka, Japan) ( [Fig. 1] ). A covered metal stent (diameter 8 mm, length 8 cm, Niti-S; Taewoong Medical, Gyeonggi-do, South Korea) was inserted between the intrahepatic bile duct and the Roux-en-Y jejunum ( [Fig. 2] ). The following day, the patient’s cholangitis was markedly improved, and he was discharged 3 days after surgery.
Fig. 1 Fluoroscopic image showing a common bile duct stone (arrowhead) and balloon dilator (arrows).
Fig. 2 Stent deployment between the intrahepatic bile duct and the Roux-en-Y jejunum (arrows). a Fluoroscopic image. b Endoscopic image.
The patient was re-admitted to our hospital 4 weeks later to continue treatment for CBD stones. The cholangioscope was inserted over the guidewire through the metal stent ( [Fig. 3] ), and the CBD stones were revealed by cholangioscopy ( [Fig. 4 a] ). The stones were crushed by electronic hydraulic lithotripsy ( [Fig. 4 b] ). Subsequently, the metal stent was removed and a balloon dilator was inserted into the fistula toward the ampulla and dilated up to 12 mm ( [Fig. 5 a] ). The CBD stones were pushed out into the digestive tract in an antegrade fashion using a balloon catheter ( [Fig. 5 b] ). Finally, a single-pigtail plastic stent (7 Fr, 20 cm length)  was deployed between the CBD and the Roux-en-Y jejunum ( [Fig. 6] ). The patient resumed eating 4 days after surgery with no adverse effects, and was discharged 7 days after surgery.
Fig. 3 Insertion of the digital peroral cholangioscope (arrows) over the guidewire through the metal stent (arrowheads).
Fig. 4 Treatment of common bile duct (CBD) stones. a Cholangioscopic view showing CBD stones (arrows). b Crushing of CBD stones by electronic hydraulic lithotripsy.
Fig. 5 Removal of common bile duct (CBD) stones. a Fluoroscopic image showing endoscopic papillary balloon dilation (arrows). b Use of a balloon catheter (arrowhead) to push CBD stones into the digestive tract in an antegrade manner.
Fig. 6 Fluoroscopic image showing deployment of a single-pigtail plastic stent between the common bile duct and the Roux-en-Y jejunum (arrows).
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1 Navaneethan U, Hasan MK, Kommaraju K. et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc 2016; 84: 649-655
2 Tanaka R, Itoi T, Honjo M. et al. New digital cholangiopancreatoscopy for diagnosis and therapy of pancreaticobiliary diseases (with videos). J Hepatobiliary Pancreat Sci 2016; 23: 220-226
3 Umeda J, Itoi T, Tsuchiya T. et al. A newly designed plastic stent for EUS-guided hepaticogastrostomy: a prospective preliminary feasibility study (with videos). Gastrointest Endosc 2015; 82: 390-396
Ken Kamata, MD, PhD
Department of Gastroenterology and Hepatology
Kindai University Faculty of Medicine
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