Post written by Tatsuya Sato, MD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

This is a case report of double-balloon endoscope-assisted direct cholangioscopy in a patient with a history of total gastrectomy and Roux-en-Y (R-Y) reconstruction. Electrohydraulic lithotripsy (EHL) was necessary to remove large and multiple bile duct stones. First, direct insertion of a double-balloon endoscope (DBE) into the bile duct was attempted, but the ampulla was too small even after large-balloon dilation. Therefore, we removed the scope keeping the overtube in situ, and the ultraslim endoscope was successfully advanced through the overtube into the bile duct. After EHL under direct visualization, bile duct stones were completely removed.

Treatment of large bile duct stones in surgically altered anatomy patients is still difficult using DBE-assisted endoscopic retrograde cholangiography (DBE-ERC). We previously reported the effectiveness of EHL under direct cholangiography using a DBE itself (Endoscopy. 2015;47 Suppl 1 UCTN:E519-20), but this procedure requires a sufficient opening of the ampulla of Vater or the anastomosis of hepaticojejunostomy. In cases with a relatively small orifice as inthis case, we think this scope-exchange technique can be a useful treatment option.

DBE-ERC has been reported to be an effective treatment alternative to percutaneous or surgical intervention for bile duct stones in patients with surgically altered anatomy. However, there are still some technical hurdles during therapeutic interventions. Our technique can expand the indication of endoscopic treatment for choledocholithiasis in surgically altered anatomies.

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