Endoscopic ultrasound-guided antegrade bile duct stone treatment followed by direct peroral transhepatic cholangioscopy in a patient with Roux-en-Y reconstruction.

Endoscopic ultrasound (EUS)-guided antegrade treatment for biliary disorders was developed for patientswith an altered anatomy [1–5]. This report describes a case of successful EUS-guided bile duct stone (BDS) treatment followed by direct peroral transjejunal-hepatic cholangioscopy in a patient with Roux-en-Y reconstruction. An 80-year-old woman with a BDS and a history of total gastrectomy with Rouxen-Y reconstruction was admitted to the Hokkaido University Hospital. The papilla could not be reached even with balloon enteroscopy. Therefore, transhepatic EUSguided antegrade BDS treatment was attempted. A B3 branch duct was punctured using a 19-gauge needle (SonoTip Pro Control; Medi-Globe GmbH, Rosenheim, Germany), and a 0.025-inch guidewire (VisiGlide 2; Olympus Medical Systems, Tokyo, Japan) was placed (●" Video 1). A 6-Fr wireguided diathermic dilator (Cysto-GastroSet; Endo-Flex GmbH, Voerde, Germany) was used to dilate the tract. Papillary balloon dilation (Hurricane RX Biliary Balloon Dilatation Catheter; Boston Scientific Japan, Tokyo, Japan) was also performed under fluoroscopic guidance according to the size of the distal bile duct (●" Fig.1a,●" Video 1). The retrieval balloon (Extractor Pro RX retrieval balloon catheter, 15–18mm; Boston) and mechanical lithotripter (Litho Crush V, BML-V437QR-30; Olympus) both failed to extract the stone (●" Video 1). A 6-Fr nasobiliary drainage catheter (NBDC; Flexima ENBD Catheter; Boston Scientific Japan) was placed across the papilla for drainage into the duodenum and to facilitate a rendezvous procedure using balloon enteroscopy (●" Fig.1b). The next day, the patient developed acute cholangitis. Re-intervention through the fistula tract was attempted. After advancing the guidewire into the bile duct, the BDS was captured by a standard basket catheter (FG-V435P; Olympus) (●" Fig.1c, ●" Video 1). However, the basket catheter could not pass the papilla and was impacted instead (●" Video 1). Emergency, di-