Electrohydraulic lithotripsy under peroral direct cholangioscopy using short-type single-balloon enteroscope for large common bile duct stone in patients with Roux-en-Y gastrectomy.

Abstract

Balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography (BEA-ERCP) has improved the outcomes of ERCP in patients with reconstructed gastrointestinal anatomy [1,2]. However, BEA-ERCP requires high technical expertise, and large stones in the common bile duct (CBD) are difficult to treat. Binmoeller at al. reported that electrohydraulic lithotripsy (EHL) is useful for the treatment of CBD stones that could not be engaged in the basket in patients with normal gastrointestinal anatomy [3]. EHL with an ultraslim endoscopeduring peroral direct cholangioscopy (PDCS) [4], and EHL with a single-balloon enteroscope under PDCS [5] havebeen reported inpatientswithhepaticojejunostomy. This report describes a 78-year-old man with gastric cancer who underwent Roux-en-Y total gastrectomy. EHL was performed with a short-type single-balloon enteroscope (prototype, SIFY0004V01; Olympus Medical Systems, Tokyo, Japan) under PDCS. The patient was admitted during a weekend with abdominal pain and fever, and was diagnosed with cholangitis due to CBD stones. The patient underwent BEAERCP 2 days after admission. Bile duct cannulationwas performed using the doubleguidewire technique (● Video1). Cholangiography revealed a shadow defect, 30×20mm, in the CBD. Endoscopic papillary large balloon dilation was performed using a 15–18-mmballoon dilation catheter (CRE; Boston Scientific, Natick, Massachusetts, USA). The notch on the balloon disappeared after the balloon was dilated to 15mm. The single-balloon enteroscope was inserted into the CBD, using a dilated balloon as an anchor, and a large stone was seen (● Fig.1,● Video2). The stone was crushed using EHL during PDCS (● Video3). The stone fragmentswere removed using a 4-wire wire-guided retrieval basket and retrieval balloon (● Video4). The time required to reach the papilla was 11 minutes. The procedure time was 56 minutes. No procedure-related adverse events occurred. Abdominal pain and cholangitis improved rapidly, and the patient was discharged the following day. These results suggest that EHL with an single-balloon enteroscope during PDCS is a useful procedure in patients with Roux-en-Y gastrectomy.