Post written by Azimudin Haja, MD, DM, Aniruddha Pratap Singh, DM, and Sundeep Lakhtakia, MD, DM, from AIG Hospitals, Hyderabad, India.

Our case highlights the challenges faced in managing a patient with complex clinical problems several years after major surgery. The index patient who underwent curative pancreatoduodenectomy surgery 13 years ago for periampullary cancer presented with cholangitis because of a large common hepatic duct stone and a bilioenteric anastomotic stricture. Prior attempts by percutaneous approach were partially successful. An informed decision to manage endoscopically by EUS and ERCP in a staged manner was considered.

The first endoscopic procedure was EUS-guided hepaticogastrostomy (HGS) meant to create access to the dilated left intrahepatic bile duct from the stomach using a 10-mm-diameter, 8-cm-long fully covered self-expandable metal stent (FCSEMS; Giobor, Taewoong, Gimpo-si, South Korea). This was followed by an attempt at stone fragmentation using intraductal lithotripsy (laser, basket) via the stomach through the HGS FCSEMS route.

Both methods of breaking the biliary stone were unsuccessful because of improper alignment of accessories and direction of the bile duct. Extracorporeal shock wave lithotripsy was then considered as the fallback option. A nasobiliary drain was placed via the HGS FCSEMS followed by 2 sessions of extracorporeal shock wave lithotripsy that led to complete fragmentation of the large common hepatic duct stone. Using duodenoscope, we dilated the hepaticojejunostomy stricture with a balloon (passed through the HGS FCSEMS), and all the fragmented stones were pushed into the jejunum.

After complete clearance of the biliary system, the FCSEMS was removed, leaving a long plastic double-pigtail stent (gastro-hepatobiliary-jejunal ring drainage). The plastic stent was removed at 3 months after the last endoscopic intervention. The patient has been asymptomatic with normal biochemistry at 3 years of follow-up.

Benign biliary disorders (such as strictures and stones) against the backdrop of altered postsurgical anatomy pose a tricky challenge. EUS offers a potential therapy in such scenarios by providing crucial biliary access and drainage or any other intervention deemed fit. Our index patient had altered surgical anatomy with a large biliary stone, and several methods were innovatively used for lithotripsy (intraductal and extracorporeal) for ultimate clinical success.

Cholangiogram via hepaticogastrostomy using a fully covered self-expandable metal stent shows a large common hepatic duct stone with a double-pigtail stent (gastro-hepatobiliary-jejunal ring drainage). 

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