Post written by Jaehoon Cho, MD, and Ara B. Sahakian, MD, from the Department of Internal Medicine, Los Angeles County Hospital and University of Southern California Medical Center, and the Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA.

In this video, we describe successful balloon overtube-assisted ERCP with direct cholangioscopy, laser lithotripsy, and stent placement in a patient with surgically altered anatomy. An 86-year-old female patient with history of gastric cancer status post-distal gastrectomy with Roux-en-Y reconstruction presented with abdominal pain, jaundice, and leukocytosis. Computed tomography scan demonstrated multiple large bile duct stones.

Double-balloon ERCP was initially performed. After identifying large filling defects measuring up to 2 centimeters on cholangiogram, a 7-French stent was placed given concern for cholangitis, and a needle-knife sphincterotomy was performed to aid in future access.

Two months later, single-balloon ERCP was performed for stone extraction. Initial extraction attempt failed after performing papillary dilation with a controlled radial expansion balloon to 15 mm. Subsequently, the enteroscope was removed from the overtube while leaving the 0.035-inch guidewire in place. The Spyglass cholangioscope was advanced directly through the overtube into the bile duct, and laser lithotripsy was performed. After stone fragmentation, an extraction balloon was used to remove stone fragments and a 10-French stent was placed directly through the overtube under fluoroscopic guidance. Three months later, cholangiogram confirmed complete clearance of the bile duct.

ERCP in patients with surgically altered anatomy remains challenging. Large bile duct stones are especially difficult to remove with deep enteorscopy due to limitations in endoscope and accessory technology. This case highlights the use of the balloon overtube to enable direct laser lithotripsy and stent placement under fluoroscopy, overcoming the channel-size limitations of the enteroscope.

Patients with surgically altered anatomy and large bile duct stones can be successfully managed using minimally invasive endoscopic methods, avoiding potentially risky surgical interventions. The overtube is a useful tool that enables direct access to the bile duct, allowing interventions such as laser lithotripsy or placement of large diameter stents, which would not otherwise be possible with an enteroscope.

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