Post written by Arjun Chatterjee, MD, from the Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
A 61-year-old man presented with intermittent right-upper-quadrant pain, nausea, and vomiting. A CT scan of his abdomen revealed choledocholithiasis and large cholelithiasis. His medical and surgical history included severe obesity, Roux-en-Y gastric bypass, bowel perforation with extensive resection, and short gut syndrome. He was deemed to be at high surgical risk and referred for endoscopic management.
EUS was used to identify the excluded stomach from the Roux limb, and a contrast saline mixture with methylene blue was injected into it. Next, a cautery-enhanced 15- x 10-mm lumen-apposing metal stent (LAMS) was deployed. Prompt egress of methylene blue-tinged contrast material confirmed the correct placement and creation of the jejunogastrostomy.
Three weeks later, the patient returned, and ERCP via jejunogastrostomy was performed with biliary sphincterotomy and successful removal of 2 common bile duct stones.
Subsequently, linear EUS was advanced through the jejunogastrostomy, and EUS-guided gallbladder drainage was performed. A cautery-enhanced 15- x 10-mm LAMS was then used to accomplish a cholecysto-duodenostomy. Prompt egress of bile and small stones confirmed placement.
After 4 weeks, the patient was brought back for elective direct cholecystoscopy, electrohydraulic lithotripsy, and removal of the large cholelithiasis. Electrohydraulic lithotripsy was performed under continuous irrigation with fragmentation of the stone. The gallstone fragments were completely removed with a basket and a retriever net.
At the end of the procedure, both LAMSs were removed, and the jejunogastrostomy fistula was treated with mucosal denudation with argon plasma coagulation to allow fistula closure. Follow-up upper GI series at 6 weeks confirmed complete closure of the jejunogastrostomy fistula.
A repeat CT scan of the abdomen with oral contrast conducted 3 months after the procedure revealed no opacification of the remnant stomach, and contrast was shown to flow into the small intestine, indicating fistula closure. The patient has been monitored for over a year with no adverse consequences.
Our case demonstrates that EUS-guided biliary intervention in patients with altered anatomy is safe and feasible in experienced hands. To our knowledge, we present the first reported case of EUS-guided jejunogastrostomy, cholecysto-duodenostomy with direct cholecystoscopy, and electrohydraulic lithotripsy in a patient with Roux-en-Y gastric bypass anatomy.
Our patient had a unique scenario of concomitant choledocholithiasis and large (>3 cm) cholelithiasis. He was at high surgical risk, and the percutaneous route would have required a hybrid approach for large gallstone removal and likely an additional percutaneous transhepatic approach for management of choledocholithiasis.
Furthermore, prolonged percutaneous drains add to the morbidity from adverse events such as pain, dislodgement, leaks, and infection. Therefore, EUS-guided gallbladder drainage and EUS‑directed transgastric ERCP were performed.
Significant emerging data address the safety and efficacy of EUS-guided intervention for acute cholecystitis. As illustrated by our case, indications can be expanded to include cholelithiasis with concomitant choledocholithiasis and/or biliary pancreatitis.
Mucosal denudation being performed with argon plasma coagulation.
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