Post written by Amy Tyberg, MD, from the Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA

This case describes an elderly patient post-cholecystectomy with a markedly dilated bile duct and significant, persistent stone burden despite standard stone extraction techniques who ultimately achieved bile duct clearance with placement of a through-the-scope, self-expanding, fully-covered esophageal stent followed by direct cholangioscopy.

This video is important because it illustrates the feasibility and efficacy of using esophageal stents in markedly dilated bile ducts. This patient underwent multiple ERCPs with standard stone extraction techniques including sphincterotomy, sphincteroplasty, balloon sweep, mechanical and laser lithotripsy, serial metal stenting, and cholangioscopy but continued to have a persistent stone burden. Because of the dilated duct diameter, a standard biliary stent was unable to provide sustained patency and stone dissolution due to migration. By placing an 18mm diameter stent, the bile duct was finally able to fully empty and complete clearance could be achieved. Additionally, aggressive stone extraction techniques can often cause bleeding at the ampulla, as in this case.

The large diameter of the stent was able to provide successful hemostasis after standard balloon tamponade was ineffective. We believe that this technique can be added as part of the armamentarium for patients with markedly dilated bile ducts and refractory choledocholithiasis.