Successful treatment of postoperative intrahepatic stones with direct peroral cholangioscopy and mother–baby system cholangioscopy

A 73-year-old woman underwent pyloric resection and B-1 reconstruction for gastric cancer followed by duodenal bile duct anastomosis to treat common bile duct stones. The patient was later referred for bile duct dilation examination. Magnetic resonance imaging revealed intrahepatic gallstones in the posterior intrahepatic bile duct. Consequently, endoscopic retrograde cholangiopancreatography was performed.

Initially, direct peroral cholangioscopy (POCS) with an endoscope equipped with water-jet functionality was used to attempt stone fragmentation via electrohydraulic lithotripsy (EHL). However, this approach failed due to challenging angulation of the bile duct, which obstructed access to the posterior biliary duct. Subsequently, the mother–baby technique was employed using a duodenoscope and cholangioscope (SpyScope; Boston Scientific, Marlborough, MA, USA). However, advancing the SpyScope into the posterior biliary duct was unsuccessful due to the instability of the duodenoscope, which impeded the effective transmission of force and passage beyond the bend.

To address the need for greater scope stability and rigidity, a colonoscope (CF HQ290ZI, channel diameter 3.7 mm; Olympus Medical Systems, Tokyo, Japan) was introduced through the choledochoduodenal anastomosis, effectively serving as the mother endoscope. This combination of direct POCS and the mother–baby system, referred to as combined-POCS, significantly improved scope stability and enhanced the insertability of the choledochoscope. This rigidity of the colonoscope helped facilitate successful access to the posterior biliary branch (Figs 1,2). Complete stone removal was achieved using stone fragmentation with EHL (Video S1).

Generally, EHL is effective in treating intrahepatic stones,^{1, 2} but its success is often limited by the devices used in the postoperative intestinal tract.³ In this case, the sequential application of various treatment methods led to effective resolution. The therapeutic intervention proceeded without adverse events, demonstrating the efficacy of combined-POCS in the management of postoperative intrahepatic stones.

Authors declare no conflict of interest for this article.