Post written by Ryuichi Tezuka, MD, from the Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan.

We presented electrohydraulic lithotripsy (EHL) under the mother-baby cholangioscope system using a colonoscope for large common bile duct stones in a patient with Roux-en-Y reconstruction.

A man with a history of Roux-en-Y reconstruction for gastric ulcer and radiofrequency ablation (RFA) for hepatocellular carcinoma was admitted to our hospital with cholangitis due to common bile duct (CBD) stones (CBDSs). Endoscopic retrograde cholangiography was planned using a short-type, double-balloon endoscope. However, the main papilla was oriented vertically toward the intestine, and the catheter could not be inserted into the CBD. Percutaneous transhepatic biliary drainage (PTBD) was performed on the right side of the intrahepatic bile duct during the same procedure. Because the patient had severe cirrhosis and the RFA scar in S8, he was considered to have a risk of developing a biloma in this scar with stone removal using the PTBD route. 

In the second session, the catheter was inserted into the CBD using the PTBD-rendezvous technique. Endoscopic papillary large balloon dilation was subsequently performed. However, there was no space to deploy the basket catheter because the large CBDSs were obstructing the CBD and the distal CBD was narrow. Therefore, we could not capture and remove all the CBDSs with this method.

In the third session, we considered the use of a cholangioscope with a mother-baby system and used a colonoscope to insert the cholangioscope into the CBD. After the colonoscope reached the main papilla, the cannula was smoothly inserted into the CBD. The guidewire was then inserted into the CBD and used to guide cholangioscope insertion through the colonoscope into the CBD. EHL was then performed under cholangioscopy, and all of the CBDSs were successfully removed using a basket and balloon catheter.

When the patient has undergone Roux-en-Y reconstruction, using the mother-baby cholangioscope system is difficult because the working channel of the enteroscope is narrower than the cholangioscope. In this case, although CBDSs were large and the distal CBD was narrow, we could remove all CBDSs using EHL with a mother-baby cholangioscope system. We believe this case study makes a significant contribution to the literature because we describe the effective treatment option for cases of large CBDSs in Roux-en-Y reconstruction.

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