Percutaneous antegrade cholangioscopy with a novel short cholangioscope in altered anatomy. These are our disclosures. A 66-year-old gentleman presented with choledocal lathiasis, causing cholangitis and acute pancreatitis. He was known for a remote duodenal switch and sleeve gastrectomy six years prior. A cholecystectomy had been performed two years prior. This diagram demonstrates the anatomy post-duodenal switch surgery. It was not thought that enteroscopy-assisted ERCP would be possible given the long length of the digestive limb and of the biliopancreatic limb. Given the presence of cholangitis, percutaneous biliary drainage was performed with an 8.5 French stent. Endoscopic ultrasound-directed transenteric ERCP was attempted using contrast and methylene blue injection via the percutaneous drain. No safe site for puncture was identified via endoscopic ultrasound. The percutaneous biliary drain was therefore upsized to a 14 French stent to allow for antigrade passage of the 10.8 French novel short cholangioscope into the bile duct. The short cholangioscope is 65 cm long compared to the traditional 214 cm cholangioscope. This allows for easier maneuverability by a single operator when the cholangioscope is used via the antigrade percutaneous route. The bile duct stone is visualized cholangioscopically. A 1.9 French electrohydraulic lithotripsy catheter is passed through the working channel of the 3.6 French cholangioscope and used to fragment the bile duct stone into smaller and smaller pieces. The novel short cholangioscope has a tighter angulation of the distal tip, which allows for easier maneuverability around sharp corners when compared to the traditional cholangioscope. A tight angulation was encountered at the junction of the right and left hepatic ducts. Using a short cholangioscope, it was possible to target the stone nonetheless and fragment it using electrohydraulic lithotripsy. Both stones are fragmented into smaller pieces. A 15 mm extraction balloon is passed over the wire in a percutaneous and antigrade fashion. The stone fragments were pushed down through the native papilla into the duodenum. Multiple balloon sweeps were performed. At the end of the procedure, contrasts flowed freely into the duodenum, indicating complete bile duct clearance. No percutaneous biliary drain was left in place at the end of the procedure. The patient recovered from cholangitis and pancreatitis. They were discharged home. At 19-month follow-up, no biliary or pancreatic adverse events have occurred. The management of choledocal lithiasis after duodenal switch and sleeve gastrectomy is challenging given the presence of a long elementary and pancreatic biliary limb. The use of a novel short cholangioscope can facilitate percutaneous antigrade management of biliary disease. The shorter working length of the novel cholangioscope facilitates single operator usage. A tighter distal tip angulation allows for management of stones in hard-to-reach locations. A novel short cholangioscope can facilitate management of biliary pathology in altered surgical anatomy in patients with percutaneous biliary access.

novel short cholangioscope

percutaneous antegrade cholangioscopy

altered anatomy

bile duct stone

electrohydraulic lithotripsy