Endoscopic ultrasound-guided antegrade biliary intervention for choledocholithiasis in total gastrectomy with Roux-en-Y anatomy

Endoscopic retrograde cholangiopancreatography in patients with a history of total gastrectomy and Roux-en-Y anastomosis is challenging due to the difficulty in locating the papilla ^{1 2} . Meanwhile, increased intestinal motility and the considerable distance between the anastomosed limb and the left hepatic lobe also contribute to the failure in identifying a suitable puncture path during endoscopic ultrasound (EUS)-guided biliary drainage in these patients. Therefore, selecting a favorable puncture path for the left liver in the appropriate postoperative bowel is the key to successful EUS procedures.

A 77-year-old woman with a history of total gastrectomy and Roux-en-Y reconstruction for gastric cancer was admitted to our hospital with abdominal pain. Magnetic resonance imaging revealed choledocholithiasis ( Fig. 1 ). The duodenal papilla was not located on initial endoscopy despite use of a gastroscope, colonoscope, and enteroscope. Subsequently, a linear echoendoscope was inserted into the jejunum through the anastomosis. Both afferent and efferent limbs were examined to identify an optimal puncture site for accessing the intrahepatic bile duct ( Fig. 2 ). Eventually, the intrahepatic bile duct in liver segment S2, within the afferent limb, was selected. The mildly dilated left intrahepatic bile duct (approximately 0.4 cm) was accessed using a 19-gauge puncture needle ( Video 1 ). Cholangiography revealed a stone in the common bile duct (CBD). A guidewire was inserted; however, antegrade advancement into the distal CBD was challenging. Consequently, a 6-Fr cystotome was advanced over the guidewire for tract dilation. The distal CBD was successfully accessed, and the guidewire was advanced through the duodenal papilla into the duodenal lumen. A dilation balloon was used to expand the duct to 1.0 cm sequentially ( Fig. 3 ); the stone was extracted into the duodenal lumen using a retrieval balloon. Finally, a 7 Fr × 15 cm double-pigtail biliary stent was placed, with two ends in the duodenal and jejunal lumens, respectively ( Fig. 4 ).

Fig. 1.

Magnetic resonance imaging revealed a stone in the common bile duct and mild dilation of the upstream duct (indicated by the yellow arrow).

Fig. 2.

In the endoscopic view, the efferent limb is on the left, and the afferent limb is on the right.

Fig. 3.

A dilation balloon was used to expand the common bile duct (CBD). The arrow points to a stone in the CBD.

Fig. 4.

A double-pigtail biliary stent was placed, with two ends in the duodenal and jejunal lumens, respectively.

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Endoscopic ultrasound-guided antegrade biliary intervention for choledocholithiasis in total gastrectomy with Roux-en-Y anatomy.

Video 1

Postoperatively, the patient’s serum lipase and amylase levels remained within normal limits, whereas bilirubin levels showed a mild transient elevation that normalized within 3 days. The patient was discharged 1 week after surgery.

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