Peroral cholangioscopic lithotripsy is a useful procedure in patients with a normal gastrointestinal anatomy who have difficult-to-treat stones. We evaluated the usefulness of peroral direct cholangioscopy (PDCS) using single-balloon enteroscope (SBE) in patients with difficult-to-treat stones who had undergone Roux-en-Y reconstruction.
MethodsAmong 118 patients (169 sessions) who underwent SBE-assisted endoscopic retrograde cholangiopancreatography to treat biliary stones after Roux-en-Y reconstruction, patients in whom it was difficult to remove biliary stones via a transpapillary or transanastomotic approach and difficult to switch to ultra-slim endoscope, were retrospectively enrolled. The biliary insertion success rate, procedure success rate, procedure time, and procedural complications were assessed. The SBE was inserted into the bile-duct, first using a free-hand technique, second using a guide wire, and third using the large balloon anchoring and deflation (LBAD) technique.
ResultsA total of 11 patients (14 sessions) were enrolled in this study. The biliary insertion success rate was 100%. Bile-duct insertion was performed using a free-hand technique in 4 sessions, a guide wire in 3 sessions (rendezvous technique, 2 sessions), and the LBAD technique in 7 sessions. The procedure success rate was 86% in first session, and 100% in second session. The median procedure time was 81 min (range 49–137). The median procedure time in the bile-duct was 21.5 min (range 6–60). Mild pancreatitis occurred as a complication in one patient. The median follow-up was 528 days (range 282–764). No patient had stone recurrence.
ConclusionsPDCS using SBE is a useful procedure in patients with Roux-en-Y reconstruction. The LBAD technique is an useful technique of inserting SBE into the bile-duct.
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The authors thank Olympus Medical Systems (Tokyo, Japan) for providing the prototype instruments used in this study.
FundingThe prototype instruments used in this study were provided by Olympus Medical Systems (Tokyo, Japan).
Author information Authors and AffiliationsDepartment of Gastroenterology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, Sagamihara, Kanagawa, 252-0375, Japan
Hiroshi Yamauchi, Mitsuhiro Kida, Kosuke Okuwaki, Shiro Miyazawa, Takaaki Matsumoto, Kazuho Uehara, Eiji Miyata, Rikiya Hasegawa, Toru Kaneko, Issaree Laopeamthong, Yang Lei, Tomohisa Iwai, Hiroshi Imaizumi & Wasaburo Koizumi
Correspondence to Hiroshi Yamauchi.
Ethics declarations DisclosuresHiroshi Yamauchi, Mitsuhiro Kida, Kosuke Okuwaki, Shiro Miyazawa, Takaaki Matsumoto, Kazuho Uehara, Eiji Miyata, Rikiya Hasegawa, Toru Kaneko, Issaree Laopeamthong, Yang Lei, Tomohisa Iwai, Hiroshi Imaizumi, and Wasaburo Koizumi have no conflicts of interest or financial ties to disclose.
Electronic supplementary materialBelow is the link to the electronic supplementary material.
LBAD technique The papillae was dilated with a 12-mm large balloon, and the balloon was pulled and attached to the enteroscope. Subsequently, the tip of the enteroscope was inserted into the lower bile-duct by the push technique, and the balloon was then removed while deflating. The enteroscope was passively inserted into the bile-duct. Supplementary material 1 (MP4 9737 kb)
EHL for an impacted bile-duct stone and endoscopic retrieval of a proximally migrated biliary stent (Case 3-1) After cholangiography, EPLBD was performed using a 15 mm balloon. A short-type SBE was inserted into the bile-duct using the LBAD technique and showed a proximally migrated biliary stent (that was placed for treatment of acute obstructive suppurative cholangitis before 7 days), an impacted stone, and a bile-duct ulcer associated with the stone. Electrohydraulic lithotripsy (EHL) (Lithotron EL-21 and EHL probes (A 9411) (both manufactured by Walz Elektronik, Rohrdorf, Germany) was performed to crush the impacted stone. The migrated stent was grasped with a snare and was removed along with the scope. Supplementary material 2 (MP4 25493 kb)
A biopsy of an elevated lesion in the bile-duct and biliary dilatation (Case 3-2) One month after stone removal (Video 2), contrast-enhanced CT showed an elevated lesion in the bile-duct. Cholangiography revealed a stricture in the common hepatic duct, and a defect was seen at liver side of stricture. Intraductal ultrasonography showed thickening of the wall at the site of the narrowed bile-duct. A hyperechoic region suggestive of debris was seen at liver side of stricture. A short-type SBE was inserted into the bile-duct, using the LBAD technique. An elevated lesion was seen in the common hepatic duct. Debris was removed with a grasping forceps and a 5-prong forceps. Endoscopic examination suggested that the elevated lesion was benign. However, a biopsy of the elevated lesion was performed to rule out the presence of malignant disease. The stricture was dilated with a balloon. The biliary cast syndrome was diagnosed by histopathological examination of debris tissue. Supplementary material 3 (MP4 22467 kb)
Biliary dilation and stone removal using a 5-prong grasping forceps (Case 7) MRCP showed multiple stones in the left and right intrahepatic bile-ducts. Because the stones could not be removed from the left hepatic duct, direct cholangioscopy was performed and showed a stricture at the origin of the left hepatic duct. The stricture was dilated with a 12-mm balloon. Stones in the left hepatic duct were removed using a 5-prong grasping forceps. After stone removal, an enteroscope was inserted into the left hepatic duct to wash the bile-duct and to confirm the absence of residual stones. Supplementary material 4 (MP4 14787 kb)
About this article Cite this articleYamauchi, H., Kida, M., Okuwaki, K. et al. Therapeutic peroral direct cholangioscopy using a single balloon enteroscope in patients with Roux-en-Y anastomosis (with videos). Surg Endosc 32, 498–506 (2018). https://doi.org/10.1007/s00464-017-5742-3
Received: 07 December 2016
Accepted: 14 July 2017
Published: 21 July 2017
Issue Date: January 2018
DOI: https://doi.org/10.1007/s00464-017-5742-3
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