Ryosuke Tonozuka, MD, from the Department of Gastroenterology and Hepatology at Tokyo Medical University in Tokyo, Japan presents this VideoGIE case, “Holmium: YAG laser lithotripsy through an EUS-guided hepaticogastrostomy route.”

Treatment of biliary calculi in patients with surgically altered anatomy is often challenging despite the development of balloon enteroscopy (BE). This video showed holmium: YAG laser lithotripsy (YAG-LL) via an EUS-guided hepaticogastrostomy (EUS-HGS) site for an impacted stone in the intrahepatic bile duct in a patient after pancreaticoduodenectomy.

First, BE-guided endoscopic retrograde cholangiography, dilation of the anastomosis by using a balloon dilator and removal of the stones were performed. However, 1 impacted stone behind the left IHBD stricture due to repeated cholangitis remained. Next, EUS-HGS was performed by using a fully covered self-expandable metal stent (FCSEMS) (8 mm in diameter, 6 cm in length). One week later, YAG-LL through the FCSEMS under per-oral video cholangioscopic visualization was performed, and the stone was removed completely.

The patient’s symptoms rapidly disappeared. CT on the following day showed disappearance of the stones. One month later, the FCSEMS was removed. YAG-LL through EUS-HGS route was safety and effective.

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