Successful management of biliary stones in the hepatic duct after a Whipple procedure by using an EUS-guided antegrade approach and temporary metal stent placement

摘要

A 78-year-old woman with a history of distal gastrectomy for gastric cancer with Billroth II reconstruction and a Whipple procedure for lymph node recurrence had multiple biliary stones. Endoscopic retrograde cholangioscopy with a pediatric colonoscope failed to reach the biliary orifice because of complicated surgically altered anatomy. EUS-guided antegrade (EUS-AG) treatment was then performed (Fig. 1; Video 1, available online at www. giejournal.org). The biliary duct was accessed from the remnant stomach under EUS guidance followed by balloon dilation of the anastomosis and stone removal through the anastomosis by using a retrieval balloon. The first session was terminated after nasobiliary drainage (NBD) tube placement because of the prolonged procedure time. In the second session, an attempt at complete stone removal by using a side-viewing endoscope again failed because the anastomosis could not be adequately dilated. In the third session, the use of a fully covered metal stent (CMS) at the fistula enabled complete stone clearance with a basket catheter through it. The CMS was removed 2 days later. NBD was removed after confirmation of complete stone clearance. There were no adverse events during the sessions. EUS-AG treatment with temporary CMS placement is a potential management option for difficult biliary stones, although further evaluation is required.