VIDEO CASE REPORT

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EUS-guided hepaticojejunostomy with transjejunal per-oralcholangioscopy and electrohydraulic lithotripsy in a patient withcomplicated choledocholithiasis after Roux-en-Y gastric bypass

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Johannes Maubach, MD, Maja Gruber, MD, Philipp Nett, MD, Andrew J. Macpherson, MD, PhD,Mathias Worni, MD, MHS

Obesity and rapid weight loss after bariatric surgery areestablished risk factors for gallstone disease. Especially af-ter Roux-en-Y gastric bypass (RYGB), conventional ERCPis rarely successful in patients with symptomaticcholedocholithiasis.

The success rate can be increased up to 70% byenteroscopy-assisted ERCP; however, this procedure iscumbersome and time-consuming. Percutaneous transhe-patic cholangiography with drainage or laparoscopic-assisted ERCP are current alternatives if the endoscopicapproach fails. In addition, recent reports have statedthat the remnant stomach can be accessed either percuta-neously or by EUS-guided stent placement, offering subse-quent papillary access.

Here we report the case of a 66-year-old man who wasadmitted with septic cholangitis due to choledocholithiasis(Fig. 1). He had undergone RYGB with cholecystectomy

T scan showing intrahepatic and extrahepatic bile ducts withng stone in the distal common bile duct (CBD).

script of the video audio is available online at www.VideoGIE.org.

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8 years earlier because of morbid obesity. Upperendoscopy showed a small gastric pouch with an opengastrojejunostomy (Fig. 2).

Figure 2. Upper endoscopic view revealing a small gastric pouch afterRoux-en-Y gastric bypass.

Figure 3. EUS view confirming dilated intrahepatic bile ducts.

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Figure 4. Final endoluminal position of the fully covered metal stentcreating a hepaticojejunostomy.

Figure 5. Cholangiographic view 6 weeks after transjejunal cholangio-scopy with electrohydraulic lithotripsy, confirming stone-free biliarysystem.

Figure 6. Cholangioscopic view without any evidence of residual stonefragments.

Video Case Report Maubach et al

EUS revealed dilated intrahepatic bile ducts (Fig. 3), andthe gastric remnant could not be visualized. To relievecholestasis, EUS-guided biliary drainage connecting hepat-ic segment III with the Roux-en-Y limb was performed by

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the insertion of a self-expanding covered metal stent(SEMS) (Fig. 4).

Three weeks later, after maturation of the hepaticojeju-nostomy, a transjejunal cholangioscopy was performed byadvancing a spyscope through the SEMS. A 2-cm biliarystone was identified in the mid–common bile duct andwas fragmented by electrohydraulic lithotripsy (EHL).A second stone was found in the prepapillary region, distalto the first stone. EHL was successfully repeated in thesame fashion.

Finally, the papilla was cannulated, and a guidewire waspassed into the duodenum. The papilla was dilated to10 mm, and a 10F 15-cm double-pigtail stent was inserted,extracting the SEMS during the same process (Video 1,available online at www.VideoGIE.org). Six weeks later,during follow-up endoscopy, injection of contrast materialinto the biliary system showed a completely cleared com-mon bile duct (Fig. 5). Even repeated cholangioscopycould not reveal any residual stone fragments (Fig. 6).The patient remains well; no further endoscopy is planned.

Transenteric access to the biliary system through the leftliver lobe is a novel alternative route in patients with biliarydisease, especially in patients with altered anatomy whereconventional ERCP is not easily feasible. Given the growingnumbers of RYGB patients, this procedure offers anappealing method of treatment compared with percuta-neous transhepatic cholangiography with drainage,

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Maubach et al Video Case Report

enteroscopy-assisted ERCP, or a surgical approach. Trans-enteric per-oral cholangioscopy in combination with EHLappears to be safe and effective, but long-term data aredefinitely warranted.

DISCLOSURE

All authors disclosed no financial relationshipsrelevant to this publication.

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VideoGIE is now indexed in PubMed Central.

VideoGIE is an Open Access, online-only jourvideo cases of endoscopic procedures used indigestive diseases.

VideoGIE publishes the following article type

• Case Reports: Reports of the diagnosis anda single case.

• Case Series: Reports of the diagnosis and mor more cases.

• Tools and Techniques: Educational videosendoscopic tool or technique. The goendoscopy nurses, and technicians lecopy for high-quality care.

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Abbreviations: EHL, electrohydraulic lithotripsy; RYGB, Roux-en-Y gastricbypass; SEMS, self-expanding covered metal stent.

Department of Visceral and Transplantation Surgery, Inselspital, BernUniversity Hospital, University of Bern, Bern, Switzerland.

Copyright ª 2018 American Society for Gastrointestinal Endoscopy.Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

https://doi.org/10.1016/j.vgie.2018.07.017

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