Ryan Law, DO from the Division of Gastroenterology and Hepatology at Mayo Clinic in Rochester, Minnesota, USA presents this video case “Endoscopic removal of a large common bile duct stone: more than one way to skin a cat.”
This video demonstrates successful removal of a “cat’s eye” calculus within the common bile duct using single-balloon enteroscopy to perform direct peroral cholangioscopy in a patient with surgically-altered anatomy. This patient had a remote Billroth II operation for peptic ulcer disease and prior cholecystectomy, likely the cause of the retained surgical clip nidus. He presented to our institution after undergoing ERCP with plastic biliary stent placement elsewhere. Cholangiography with complete biliary sphincterotomy was initially performed using a standard duodenoscope. Attempts to fracture or remove the 15mm stone using standard methods were unsuccessful. Ultimately, a single-balloon enteroscope with overtube was passed to the dilated papillary orifice and direct cholangioscopy was performed. An electrohydraulic lithotripsy probe progressively fractured the stone until the surgical clip nidus was visualized. The clip and the majority of the stone debris was removed. A 7F, 7cm plastic biliary stent was placed. Repeat ERCP 8 weeks later demonstrated complete duct clearance.
Figure 1. Cholangiogram demonstrating a large “cat’s eye” calculus in the distal common bile duct.
This case demonstrates alternative methods to perform cholangiography and execute definitive interventions within the biliary tree of patients with surgically-altered anatomy when standard methods are insufficient.
In patients with a biliary stone secondary to a foreign body, it is imperative that the foreign body be removed to prevent additional stone formation. In this case a sizable stone had formed around the surgical clip, thus removal of large stone fragments and the clip were paramount. Though a challenging procedure, a single-balloon enteroscope can be utilized as a peroral cholangioscope, as documented by many authors. However, this requires dilation of the papillary orifice and favorable enteroscope position.
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