Post written by Hassan Atalla, MSc, and Arata Sakai, MD, PhD, from the Hepatology and Gastroenterology Unit, Department of Internal Medicine, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt, and the Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan.
A 60-year-old man with history of Roux-en-Y hepaticojejunostomy for pancreatico-biliary maljunction was presented with acute cholangitis on the background of a large impacted intrabiliary stone. Traditionally, double-balloon enteroscopy was used for mechanical lithotripsy or balloon-assisted sweeping of that impacted stone. However, all these attempts were unsuccessful, and subsequently, we thought about the use of overtube-guided electrohydraulic lithotripsy (EHL) via digital cholangioscopy. This technique depends on enabling a wire-guided digital cholangioscope (DC) to reach the bilio-enteric anastomosis in patients with surgically altered anatomy (SAA) through the enteroscopy-overtube after enteroscope withdrawal. While attempting this procedure, we faced unexpected challenges including a severely kinked course of the overtube in relation to the reconstructed anatomy, which hindered a smooth passage of the DC. Nonetheless, with the assistance of prolonged trials of tube repositioning through external abdominal compressions, the DC successfully overcame the kinked area and passed out of the overtube. The next challenge was faced after accidental slippage of the guidewire out of the bilio-enteric anastomosis while trying to admit the DC into the biliary tract. The main problem was the loss of our endoscopic view in the collapsed jejunum since DC was not designed to insufflate air. Salvaging this troublesome situation, we tried to enhance DC capabilities to directly insufflate carbon dioxide (CO2) for regaining jejunal lumen patency. A short plastic tube, simply obtained through cutting distal 3 cm of a conducting tube of an oxygen nasal cannula, was used to directly connect a CO2 pump to the DC working channel through which CO2 was maintained under high pressure. This technique succeeded in keeping lumen patency and gave a chance for the DC to view the anastomosis site with subsequent direct cannulation and EHL of the large impacted stones with further fragmentation.
Enteroscopy-assisted ERCP in patients with SAA usually represent a dilemma. However, it is still considered as the first treatment option for such cases when compared to the more invasive EUS-guided or surgical procedures. This video case represents more challenges, which were mainly related to the reconstructed anatomy and the demanding procedure technique.
We believe that detailed discussion of such endoscopic procedures will definitely enhance the familiarity and experience of other endoscopists in this enthusiastic field and help in managing future problematic cases. Moreover, the simple solutions we have proposed in this video can help other endoscopists to overcome such challenges when faced again.
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