PMC7676982_01
Schematic of surgically altered gastrointestinal anatomy: partial gastrectomy with Roux-en-Y gastrojejunostomy.
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Upper GI endoscopy revealed a gastric pouch with a patent Roux-en-Y gastrojejunostomy anastomosis (Figure 1).
Endoscopic ultrasound showing a dilating segment 3 biliary radicle.
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With the scope positioned in the gastric pouch, a dilated segment 3 branch was identified in the left lobe of the liver (Figure 2).
EUS-guided cholangiography showing a dilated biliary tree with choledocholithiasis.
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Cholangiogram showed diffuse intrahepatic ductal dilation and a dilated common bile duct measuring 18 mm in diameter with two large filling defects consistent with stones (Figure 3).
Balloon dilation of the HG tract.
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Tokyo, Japan) was then advanced through the needle into the biliary tree and past the major papilla into the duodenum. The hepaticogastrostomy tract was subsequently dilated using a 4 mm x 4 cm Hurricane biliary dilation balloon (Boston Scientific, Marlborough, MA, USA) (Figure 4).
EUS-HG with placement of metal and double pigtail plastic stents.
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The metal stent was anchored by a plastic double pigtail stent (7 Fr x 18 cm) with the distal end of the plastic stent placed past the major papilla and the proximal end placed in the stomach (Figure 5).
Antegrade balloon sphincteroplasty to facilitate stone removal.
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CRE (controlled radial expansion) wire-guided balloon (Boston Scientific, Marlborough, MA), and the diameter was gradually increased to 15 mm (Figure 6). Cholangioscopy was then performed using a SpyScope DS (Boston Scientific, Marlborough, MA) with visualization of two large stones in the common bile duct which were fragmented using EHL (Figure 7).
(a) Cholangioscopy showing CBD stones and (b) EHL resulting in common bile duct stone fragmentation.
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CRE (controlled radial expansion) wire-guided balloon (Boston Scientific, Marlborough, MA), and the diameter was gradually increased to 15 mm (Figure 6). Cholangioscopy was then performed using a SpyScope DS (Boston Scientific, Marlborough, MA) with visualization of two large stones in the common bile duct which were fragmented using EHL (Figure 7).
(a) Cholangiogram showing complete clearance of stones from the common bile duct. (b-d) Cholangioscopy showing normal distal common bile duct and ampulla with no residual stone disease.
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The biliary tree was then swept with a 15 mm stone extraction balloon (Cook Medical, Winston-Salem, NC) with antegrade advancement of stone fragments past the ampulla into the duodenum with subsequent duct clearance (Figure 8).