Cholangioscopy through a large balloon papillary dilation with two frontal endoscopes: therapeutic and infantile

Abstract

A 98-year-old woman with a medical history of cholecystectomy (12 years ago), partial gastrectomy (10 years ago), pacemaker implanted, and acute coronary syndrome was admitted to hospital for right upper quadrant colicky pain and moderate cholestasis (AST: 37 IU/L, ALT: 25 IU/L, ALP: 164 IU/L, GGT: 65 IU/L, total bilirubin: 0.7 mg/100). An abdominal ultrasound scan revealed an important dilatation of bile ducts due to choledocholithiasis. Endoscopic retrograde cholangiopancreatography (ERCP) was initiated with a therapeutic frontal endoscope. The patient had prior Billroth II surgery and a dilated common bile duct (CBD) due to multiple lithiasis. The biggest stone diameter ranged between 25 and 30 mm. This particular stone seamed to have resulted from the union of 2 or 3 smaller stones, joined together and stuck in the bile duct’s wall, immobile at the extraction maneuver. A 16.5 mm balloon dilation of Vater’s papilla was performed without previous sphincterotomy (Fig. 1). The therapeutic frontal endoscope was introduced along the distal CBD (therapeutic frontal endoscope cholangioscopy) in order to better define and mobilize the biggest stone. The images obtained were very clear (Fig. 2). Stone mobilization was not possible in spite of a Dormia basket and Fogarty balloon. By leaving the therapeutic frontal endoscope into the distal common bile duct, the disappearance of the normal aspect of the bile duct’s wall was noticed and a loose fiber wall net was visualized, announcing the possibility of breakage (Fig. 3). Subsequently, the therapeutic frontal endoscope was replaced by an infantile endoscope in order to reach the stone conglomerate without excessive pressure on the bile duct’s wall. The images obtained were less clear (infantile endoscope cholangioscopy). In spite of all this, stone removal was not possible. During the proce-