Figure 1.

A 73 year-old man with previous history of recurrent biliary lithiasis and pancreatitis underwent cholecystectomy and gastric-jejunal anastomosis with side-to-side choledochojejunostomy. He presented to our institution with recurrent cholangitis and ultrasound diagnosis of biliary stones in the common bile duct (CBD) (‘sump syndrome’). (a) Magnetic resonance (MR) cholangiography shows dilated CBD and intrahepatic ducts with the presence of multiple stones (arrowheads). (b) Computed tomography (CT) confirmed the MR findings: note the better visualization of the lateral choledochojejunal anastomosis (black arrow). (c) Using a right transhepatic approach (through a bile duct of the V segment) a 10 Fr biliary drainage was inserted. Cholangiography showed multiple bile stones (arrowheads) and the presence of a plastic prosthesis within the CBD (arrows). (d) After 3 days the first cholangioscopy was performed, introducing the large cholangioscope into a 16 Fr introducer sheath, by using electrohydraulic lithotripsy probes (arrowhead). Also the ampulla was dilated with a 9 mm balloon (e) and stones were pushed down with a basket-type catheter (arrow, f) after removing the plastic stent. (g) After three more sessions, final cholangiography showed optimal result: no stenosis and no stones were present in the biliary system.