Post written by Tatsuya Sato, MD, Yousuke Nakai, MD, PhD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
A 50-year-old man with a history of hepaticojejunostomy and Roux-en-Y reconstruction suffered from recurrent cholangitis due to bilateral intrahepatic stones. After failed double-balloon endoscope-assisted ERCP and percutaneous transhepatic biliary drainage, EUS-guided antegrade stone removal was attempted through the EUS-HGS fistula. Intrahepatic stones in the left lobe were antegradely extracted into the jejunum by using a retrieval balloon; however, stone extraction in the right lobe was difficult. Therefore, we inserted a digital cholangioscope through the HGS fistula and advanced into right intrahepatic bile duct. Residual stones were successfully fragmented and removed using electrohydraulic lithotripsy.
EUS-guided antegrade treatment has been a useful modality for bile duct stones in patients with surgically altered anatomies. However, approach to the right biliary system remains as one of technical hurdles. The technique showed in our video may expand the indication of EUS-guided approach to biliary tract diseases in cases with surgically altered anatomy.
Cholangioscopy combined with EHL through the EUS-HGS fistula is an effective treatment option for right side intrahepatic stones in patients with surgically altered anatomy.
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