Peroral transhepatic cholangioscopy-guided electrohydraulic lithotripsy via an endoscopic ultrasonography-guided hepaticogastrostomy route for bile duct stones in a patient with Roux-en-Y anatomy.

Endoscopic ultrasonography (EUS)-guided antegrade bile duct stone treatment has been developed for patients with altered anatomy [1–5]. Here, we present a case of successful bile duct stone treatment via an EUS-guided hepaticogastrostomy (EUS-HGS) route in the setting of prior Roux-en-Y reconstruction. Direct peroral transhepatic cholangioscopyguided electronic hydraulic lithotripsy (EHL) and endoscopic papillary large-balloon dilation (EPLBD)were used. An 84-year-old manwith bile duct stones, acute cholecystitis, cholangitis, and a history of distal gastrectomy with Roux-en-Y reconstruction was referred to our hospital. As the papilla was inaccessible even with balloon enteroscopy, only percutaneous transhepatic gallbladder drainage had been previously performed. Transhepatic EUS-guided antegrade treatment was selected for the treatment of the bile duct stones. A B3 branch duct was punctured using a 22-gauge needle, and a 0.018-inch guidewire (NovaGold; Boston Scientific Japan, Tokyo, Japan) was placed. EUS-guided antegrade cholangiography revealed multiple bile duct stones (●" Fig.1a). After exchanging to a 0.035-inch guidewire (Jagwire Plus High Performance Guidewire; Boston Scientific), we performed EPLBD (Giga, 13–15mm; Century Medical, Tokyo, Japan) under fluoroscopic guidance (●" Fig.1b), but were unable to extract the bile duct stones using a retrieval balloon (Extractor Pro RX retrieval balloon catheter, 15–18mm; Boston Scientific) (●" Video 1). A partially covered selfexpandable metallic stent (WallFlex, 10× 60mm, Boston) was placed without complications (●" Fig.1c). Then 1month later,we performedEHL under direct antegrade peroral video cholangioscopy (SpyGlass DS; Boston Scientific) using a therapeutic duodenoscope via an EUS-HGS route (●" Fig.2,●" Video 2). However, extraction of thebile duct stones, this time by basket and balloon catheter, again failed. Therefore, 2 months later, we repeated EPLBD, and achieved complete Fig.1 Transhepatic endosonography (EUS)-guided antegrade approach for attempted treatment of bile duct stones in an 84-year-old man with Roux-en-Y anatomy: radiographic views. a Multiple bile duct stones (arrows). b EUS-guided papillary balloon dilation under fluoroscopic guidance. The bile duct stones could not be extracted. c A self-expandable metallic stent was placed via the EUS-guided hepaticogastrostomy route. Inset: endoscopic image.