case_images: PMC7676982_01
case_images: Schematic of surgically altered gastrointestinal anatomy: partial gastrectomy with Roux-en-Y gastrojejunostomy.
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case_images: fig1
case_images: Upper GI endoscopy revealed a gastric pouch with a patent Roux-en-Y gastrojejunostomy anastomosis (Figure 1).
case_images: Endoscopic ultrasound showing a dilating segment 3 biliary radicle.
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case_images: fig2
case_images: With the scope positioned in the gastric pouch, a dilated segment 3 branch was identified in the left lobe of the liver (Figure 2).
case_images: EUS-guided cholangiography showing a dilated biliary tree with choledocholithiasis.
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case_images: fig3
case_images: Cholangiogram showed diffuse intrahepatic ductal dilation and a dilated common bile duct measuring 18 mm in diameter with two large filling defects consistent with stones (Figure 3).
case_images: Balloon dilation of the HG tract.
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case_images: fig4
case_images: Tokyo, Japan) was then advanced through the needle into the biliary tree and past the major papilla into the duodenum. The hepaticogastrostomy tract was subsequently dilated using a 4 mm x 4 cm Hurricane biliary dilation balloon (Boston Scientific, Marlborough, MA, USA) (Figure 4).
case_images: EUS-HG with placement of metal and double pigtail plastic stents.
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case_images: fig5
case_images: The metal stent was anchored by a plastic double pigtail stent (7 Fr x 18 cm) with the distal end of the plastic stent placed past the major papilla and the proximal end placed in the stomach (Figure 5).
case_images: Antegrade balloon sphincteroplasty to facilitate stone removal.
case_images: CRIGM2020-8866899.006.jpg
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case_images: fig6
case_images: CRE (controlled radial expansion) wire-guided balloon (Boston Scientific, Marlborough, MA), and the diameter was gradually increased to 15 mm (Figure 6). Cholangioscopy was then performed using a SpyScope DS (Boston Scientific, Marlborough, MA) with visualization of two large stones in the common bile duct which were fragmented using EHL (Figure 7).
case_images: (a) Cholangioscopy showing CBD stones and (b) EHL resulting in common bile duct stone fragmentation.
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case_images: fig7
case_images: CRE (controlled radial expansion) wire-guided balloon (Boston Scientific, Marlborough, MA), and the diameter was gradually increased to 15 mm (Figure 6). Cholangioscopy was then performed using a SpyScope DS (Boston Scientific, Marlborough, MA) with visualization of two large stones in the common bile duct which were fragmented using EHL (Figure 7).
case_images: (a) Cholangiogram showing complete clearance of stones from the common bile duct. (b-d) Cholangioscopy showing normal distal common bile duct and ampulla with no residual stone disease.
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case_images: fig8
case_images: The biliary tree was then swept with a 15 mm stone extraction balloon (Cook Medical, Winston-Salem, NC) with antegrade advancement of stone fragments past the ampulla into the duodenum with subsequent duct clearance (Figure 8).