Peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy for Roux-en-Y anastomosis

Stone extraction using endoscopic retrograde cholangiopancreatography (ERCP) is less invasive than surgical procedures. However, stone extraction in patients with surgically altered anatomy, such as those who have undergone a Roux-en-Y procedure, is challenging. Although balloon enteroscopy is useful for such cases, there is still room for improvement ^{1 2} . Peroral cholangioscopy (POCS)-guided lithotripsy can aid in the extraction of stones that are difficult to remove ^{3 4} . However, performing POCS-guided lithotripsy under balloon enteroscopy is difficult because cholangioscopes have an approximate diameter of 10 Fr and cannot pass through the forceps channel of the balloon enteroscope. This report describes a patient with a Roux-en-Y anastomosis who was successfully treated with POCS-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy.

A 51-year-old woman who had previously undergone a diversion operation and hepaticojejunostomy with Roux-en-Y for congenital biliary dilatation 7 years earlier was referred to our center. Computed tomography revealed large stones in the intrahepatic bile duct ( Fig. 1 ). Consequently, we performed ERCP using a short-type single-balloon enteroscope (SIF-H290; Olympus, Tokyo, Japan) with a working length of 152 cm and a working channel with a diameter of 3.2 mm ^{1 2} . Additionally, we performed POCS-guided lithotripsy using a thin cholangioscope (eyeMAX; Micro-Tech, Nanjing, China) with a length of 219 cm and diameter of 9 Fr ⁵ ( Fig. 2 , Video 1 ) as complete stone extraction was difficult without POCS. Cholangiography revealed large stones in the intrahepatic bile duct ( Fig. 3 ). Subsequently, POCS was performed using a thin cholangioscope, revealing multiple large stones in the intrahepatic bile duct ( Fig. 4 a ). POCS-guided lithotripsy was performed while maintaining a clear field of view ( Fig. 4 b , c ). Successful stone fragmentation was achieved ( Fig. 4 d ), followed by complete stone extraction ( Fig. 5 ).

Fig. 1.

Computed tomography revealed large stones (red arrows) in the intrahepatic bile duct.

Fig. 2.

Thin cholangioscope (eyeMAX; Micro-Tech, Nanjing, China) with a length of 219 cm and diameter of 9 Fr.

Fig. 3.

Cholangiography revealed large stones (red arrows) in the intrahepatic bile duct.

Fig. 4.

Cholangioscopy findings. a Cholangioscopy revealed multiple large stones in the intrahepatic bile duct. b , c Peroral cholangioscopy-guided lithotripsy is performed while maintaining a clear field of view. d Stone fragmentation has been successfully achieved.

Fig. 5.

Endoscopy revealed successful stone extraction.

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Successful peroral cholangioscopy-guided lithotripsy using a novel thin cholangioscope under balloon enteroscopy in a patient who had previously undergone a Roux-en-Y procedure.

Video 1

The thin cholangioscope was effective for POCS-guided lithotripsy even though a balloon enteroscope was used. This novel thin cholangioscope can improve the success rate of stone extraction in patients with a surgically altered anatomy.

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