Post written by Kazuyuki Matsumoto, MD, PhD, from Okayama University Hospital, Okayama, Japan.

Radiographic confirmation of the presence of stones remains a challenge in the treatment of intrahepatic bile duct stones in patients after hepaticojejunostomy (HJ). Peroral direct cholangioscopy (PDCS) enables direct observation of the bile duct and is useful for detecting and removing residual stones. However, its effectiveness is not clearly established in this clinical context.

Biliary pneumatosis makes distinguishing between air and stones on x-rays difficult, and incomplete stone removal can lead to recurrence of cholangitis. In cases without HJ anastomotic stricture, there is already biliary pneumatosis, whereas in cases with anastomotic stricture, biliary pneumatosis occurs after balloon dilation of the anastomotic site.

This prospective study evaluated the efficacy of overtube-assisted PDCS using an ultraslim endoscope for patients with intrahepatic bile duct stones after HJ anatomy. The success rate of PDCS was 89% (39 of 44) for patients with Child’s reconstruction and the detection rate of residual stones was 41% (16 of 39). The rate of procedure-related adverse events was 7% (3 of 44), and all improved with conservative treatment.

In conclusion, PDCS is a safe and effective procedure that enables removal of residual stones that cannot be detected radiographically, and it can potentially reduce the risk of stone recurrence. Yet, PDCS could not be performed in patients with Roux-en-Y reconstruction. The ultraslim endoscope is difficult to use in long-afferent or efferent loop bowel reconstruction because of its length (1300 mm).

Graphical abstract

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