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PERCUTANEOUS TRANSHEPATIC CHOLANGIOSCOPY FOR ELECTROHYDRAULIC LITHOTRIPSY AFTER PANCREAS-PRESERVING DUODENECTOMY: AN UNEXPECTED FINDING

Vasileios Lekakis 1, Dimitra Lakiotaki 1, Maria Tampaki 1, Stavros Papadakos 1, Chrysovalantis Vergadis 2, Andreas Koutsoumpas 1

Affiliations

1 Kapodistrian University of Athens, Athens, Greece

2 Department of Radiology, Division of Interventional Radiology, "Laiko" General Hospital, 11527 Athens, Greece, Athens, Greece

Summary

AI Generated

A 79-year-old patient with prior pancreas-preserving duodenectomy and Roux-en-Y anatomy presented with cholangitis from a 2cm biliary stone, successfully treated with percutaneous transhepatic cholangioscopy, lithotripsy, and incidental discovery of a 12mm choledochal adenomatous polyp.

Percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy successfully fragmented a 2cm biliary stone above the hepaticojejunal anastomosis when anterograde ERCP was deemed impossible due to altered anatomy.
A 12mm choledochal adenomatous polyp was incidentally discovered just above the anastomosis during the procedure, with biopsies showing enteric type tubulovillous adenoma with low-grade dysplasia.
The patient's cholestatic biochemistry almost normalized 14 days following placement of an external-internal percutaneous transhepatic drain.
This case illustrates management of biliary complications in patients with complex surgical anatomy including prior ampullary resection and Roux-en-Y reconstruction.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Clinical Case Summary

A 79-year-old patient was admitted with cholangitis. His past medical history includes pancreas-preserving duodenectomy for Vater’s ampullary lateral spreading tumor (LST) 5 years ago. At that time, frozen histology of the surgical specimen had shown low-grade dysplasia (LGD) and focal high-grade dysplasia ampullary adenoma; a very short segment of 5mm distal common biliary duct (CBD) was resected as well at that time and this was adenoma-free, finally leading to Roux en Y anatomy. During the current admission the patient underwent a CT scan that shows healthy hepaticojejunal anastomosis with a 2cm biliary stone above the anastomosis and with upstream biliary dilatation(Figure 1). In view of altered anatomy and of a long hepaticojejunal loop seen on CT scan, anterograde endoscopic retrograde cholangiopancreatography (ERCP) was deemed impossible. Percutaneous Transhepatic Cholangiography was performed instead, confirming a large filling defect above the anastomosis. Balloon dilatation of the anastomosis took place, followed by unsuccessful radiological attempts to push the stone distally. Percutaneous Transhepatic Cholangioscopy with a dedicated short single-use cholangioscope (SpyGlass™ Discover) was then performed showing a large biliary stone (Figure 2). Electrohydraulic lithotripsy was applied, fragmenting the stone in small pieces that were easily flashed down into the small bowel loop. Interestingly, following that a large (approx. 12mm in diam) choledochal adenomatous polyp was seen just above the anastomosis (Figure 3). Biopsies (SpyBite™ Max Biopsy Forceps) were taken from this polyp (these have finally shown enteric type choledochal tubulovillous adenoma with LGD). An external-internal Percutaneous Transhepatic Drain was left in place, in good position and working well. The patient had an uneventful stay, with almost normalization of his cholestatic biochemistry 14 days following the procedure.

References

Figure 1: CT scan without contrast revealed healthy hepaticojejunal anastomosis with a 2cm biliary stone (red arrow) above the anastomosis and with upstream biliary dilatation (star)-(mid CBD diam ~ 3.4cm, significant intrahepatic biliary tree dilatation)
Figure 2: Multiple stones visualized during cholangioscopy.
Figure 3: A large (approx. 12mm in diam) choledochal adenomatous polyp was revealed just above the anastomosis

Conference

UEG Week Vienna 2024

Topics

Hepatobiliary

Submission format

Clinical Case

Session

Clinical Cases (Posters)

Published

2024

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