P1751 - EUS-Hepatogastrostomy-Guided Single Operator Cholangioscopy With Laser Lithotripsy and Antegrade Biliary Drainage for Management of Difficult Biliary Stones in Surgically Altered Anatomy

Jay Bapaye, MD¹, Ashish Gandhi, MD², Amol Bapaye, MD, MS³, Rajendra Pujari, MD, MRCP^4
1Rochester General Hospital, Rochester, NY; ²Shivanand Desai Center of Digestive Diseases, Pune, Maharashtra, India; ³Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India; ⁴Shivanand Desai Center for Digestive Disorders, Pune, Maharashtra, India

Introduction: Endoscopic management of difficult common bile duct (CBD) stones in the setting of surgically altered anatomy poses significant technical challenges. Two therapeutic approaches have been described – enteroscopy assisted ERCP (e-ERCP) and endoscopic ultrasound guided biliary drainage (EUS - BD). The current video demonstrates a two-stage procedure involving EUS guidedhepatico-gastrostomy (EUS-HGS) followed by antegrade single operator cholangioscopy (SOC) with laser lithotripsy (LL) and biliary drainage for the successful management of large CBD stones in a patients with surgically altered anatomy.

Case Description/Methods: A 77-year male, post cholecystectomy and surgically altered anatomy (post gastrojejunostomy for peptic ulcer related benign pyloric stenosis) presented with fever and abdominal pain. Liver function tests were deranged(total bilirubin 4.87 mg%, direct bilirubin 3.1 mg%, SGOT 150 IU/L, SGPT 46 IU/L, ALP 186 IU/L) suggestive of biliary obstruction. MRCP revealed large CBD calculi with upstream biliary dilatation; limited EUS confirmed a dilated CBD(15.6mm). Procedure was performed in 2 sessions –session 1 – EUS-HGS was performed – the left hepatic duct was accessed under EUS guidance and a fully covered removable self-expandable metallic stent (FCSEMS) was placed for access. Session 2 after 1 week – antegrade SOC was performed through the FCSEMS and the stones were fragmented under vision using LL. The papilla was balloon dilated and the stone fragments were pushed into the duodenum using a stone retrieval balloon. A double pigtail plastic stent was placed in an antegrade manner bridging the papilla and the FCSEMS with one end in the duodenum and the other in the stomach.

Patient reported symptom relief and liver function tests improved (total bilirubin 0.97 mg%, direct bilirubin 0.35 mg%, SGOT 10 IU/L, SGPT 16 IU/L, ALP 52 IU/L). Repeat imaging demonstrated no residual calculi. The patient is scheduled for FCSEMS removal after 3 months.

Discussion: The case presented a few challenges. Firstly, evidence of large CBG stones was seen on MRCP and thus cholangioscopy was contemplated and an EUS guided approach was chosen as opposed to enteroscopy guided ERCP. Secondly, adequate anchoring of the metal stent was essential and thus a two staged procedure was planned. This video demonstrates successful EUS-HGS guided antegrade single operator cholangioscopy and laser lithotripsy and biliary drainage for management of large CBD stones in a patient with surgically altered anatomy.


Disclosures:
Jay Bapaye indicated no relevant financial relationships.
Ashish Gandhi indicated no relevant financial relationships.
Amol Bapaye indicated no relevant financial relationships.
Rajendra Pujari indicated no relevant financial relationships.


Jay Bapaye, MD¹, Ashish Gandhi, MD², Amol Bapaye, MD, MS³, Rajendra Pujari, MD, MRCP⁴. P1751 - EUS-Hepatogastrostomy-Guided Single Operator Cholangioscopy With Laser Lithotripsy and Antegrade Biliary Drainage for Management of Difficult Biliary Stones in Surgically Altered Anatomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.