An 83-year-old female patient was referred for signs of ongoing cholangitis. Medical history was significant for remote cholecystectomy and multiple preceeding endoscopic retrograde cholangiography (ERC) sessions including endoscopic papillotomy performed elsewhere. After institution of broad-spectrum antibiotics, the patient underwent repeat ERC revealing a diffusely dilated biliary system with the common bile duct (CBD) measuring up to 30mm with multiple stones up to 25mm. Endoscopic papillary large balloon dilation up to 16mm was performed and multiple stones could be extracted with or without mechanical lithotripsy and a plastic stent was inserted due to prolonged procedure time.1
The patient presented again four weeks later as scheduled for ERC with optional direct cholangioscopy (DC). While during conventional ERC again ample stone material could be extracted, fluoroscopy remained unequivocal due to marked biliary dilation. Therefore, the patient underwent freehand-intubated DC using an ultra-slim upper endoscope (working channel 2.0mm) in a retroflexed “hooking” technique2 (Fig. 1A). A large remaining stone up to 10mm could be appreciated (Fig. 1B), subsequently grasped and extracted with a 5-Fr-sheath Dormia basket (Fig. 1C). After re-insertion of the repurposed cholangioscope the biliary system could be fully visualized up to the hilum and, in part, beyond excluding further stone material3 (Fig. 1D).
(A) Retroflexed view in the descending duodenum with multiple stones during freehand intubation of the papilla for direct cholangioscopy access using an ultra-slim upper endoscope (“hooking” technique). (B) An estimated 10-mm residual biliary stone in the middle of a diffusely dilated common bile duct, (C) extracted with a small-sheath (5-Fr; working channel 2.0mm) Dormia basket. (D) Confirmation of freedom from stones with high-quality assessment of the biliary system up to the hilum and (not shown), in part, intrahepatic ducts.
Nothing to declare.
