Laser lithotripsy with balloon enteroscopy-assisted peroral cholangioscopy for a large common bile duct stone after Billroth II gastrectomy

Endoscopic procedures for large common bile duct stones in patients with altered anatomy remain challenging, despite reports on direct peroral cholangioscopy (POCS).^1-4 Recently, a novel slim cholangioscope (9F eyeMAX; Micro-Tech, Nanjing, China) facilitated balloon enteroscopy-assisted POCS (BE-POCS).⁵

An 83-year-old man, after Billroth II gastrectomy, was admitted with a large common bile duct stone. BE-POCS using a Holmium YAG (Ho:YAG) laser was employed for stone removal (Video S1). A balloon enteroscope (SIF-H290S; Olympus, Tokyo, Japan) was inserted into the afferent loop, and cholangiography revealed a large stone (15 mm) in the dilated common bile duct (20 mm). After papillary balloon dilation (15 mm), 9F eyeMAX was smoothly inserted via enteroscopy. A large stone was located in the hepatic hilum. Ho:YAG laser (LithoEVO; EDAP TMS, Lyon, France) lithotripsy effectively crushed the stone core under cholangioscope guidance (Fig. 1). The irrigation ability was sufficient to maintain a clear view because of a separate irrigation channel. A basket catheter (LithoCrush V; Olympus) was used to remove the fragments; however, the largest piece could not be extracted, and mechanical lithotripsy failed. A plastic stent was placed until the second session because of the procedure length (100 min). One month later, the largest fragment was completely crushed using the Ho: YAG laser to prevent basket impaction (Fig. 2). The green color of the laser helped detect the probe tip during the procedure. The fragmented stones were removed using a spiral basket catheter (KANEKA Medics, Tokyo, Japan). Cholangioscopy confirmed no residual stones in the intrahepatic bile ducts. Finally, small fragments were extracted using a microbasket catheter (ABIS, Hyogo, Japan) (60 min).

This is the first report of laser lithotripsy with BE-POCS for a patient with Billroth II gastrectomy. Ho:YAG laser lithotripsy using a slim cholangioscope is useful for treating difficult stones in patients with altered anatomy.

Authors declare no conflict of interest for this article.