Crush and removal of biliary stones by peroral direct cholangioscopy and W‐shaped grasping forceps after hepaticojejunostomy

Abstract

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Brief Explanation

For the removal of biliary stones in patients with surgically altered anatomy, the combination therapy of peroral direct cholangioscopy (PDCS) and electrohydraulic lithotripsy (EHL) has been reported as a useful therapy.^1-4 However, not all endoscopists can prepare and use EHL device in their hospitals because of its high price or the lack of experience. Here, we showed the video to crush and remove the biliary stones by PDCS and W‐shaped grasping forceps in patients with surgically altered anatomy.

A 79‐year‐old man was admitted to our hospital with cholangitis. He had received pancreatoduodenectomy for bile duct cancer 6 months earlier. Magnetic resonance imaging (MRI) showed a large stone (longest diameter, 13 mm) that was impacted in the hilar bile duct (Fig. 1). We performed endoscopic retrograde cholangiography using balloon‐assisted enteroscopy (BE) (EI‐530B; Fujifilm, Tokyo, Japan). Although we tried to remove the bile duct stone with a basket catheter, complete removal was difficult. Therefore, we switched from BE to PDCS with an ultra‐slim endoscope (EG‐530NW; Fujifilm), maintaining the overtube. Residual stones were recognized by PDCS (Fig. 2a). They were crushed with W‐shaped grasping forceps (FG‐4L‐1; Olympus, Tokyo, Japan) during PDCS (Fig. 2b), and crushed stones were removed with a basket catheter (Fig. 2c). Finally, residual stones were completely removed (Fig. 2d). These procedures are shown in Video S1. External diameter of the FG‐4L‐1 is 1.85 mm, so it can be inserted into an ultra‐slim endoscope’s adaptor. The FG‐4L‐1 has long, wide‐opening prongs and it looks “W‐shaped”. These wide‐opening prongs can not only crush the stones but also hold them and pull them to the outside of the bile duct. However, hard stones with shells are sometimes difficult to crush by this W‐shaped grasping forceps and EHL should be prepared at that time.

Figure 1

In magnetic resonance imaging (MRI), a large biliary stone (longest diameter, 13 mm) was impacted in the hilar bile duct. (a, axial view; b, magnetic resonance cholangiopancreatography (MRCP); biliary stone, white arrow).

Figure 2

We found residual stones by peroral direct cholangioscopy (PDCS) (a). We crushed them with W‐shaped grasping forceps (b). We then removed the stones with a basket catheter (c) and confirmed no residual stones by PDCS (d).

Authors declare no conflicts of interest for this article.