Endoscopic sphincterotomy for residual choledocholithiasis in a patient with a Billroth II gastrectomy

  • Abstract
    This video presents the case of a 54-year-old patient who underwent a Billroth II distal gastrectomy 10 years ago with an isoperistaltic anastomosis and 48 hours before he had a laparoscopic cholecystectomy for acute cholecystitis. Because of persistent pain and accentuated jaundice related to choledocholithiasis, a large sphincterotomy was performed with a duodenoscope and a standard sphincterotome used as an inverted sphincterotome. A 13.5mm balloon dilation facilitated the extraction of several 1cm bile duct stones.
  • 00'18" Clinical case presentation
    This is the case of a 54-year-old man who has undergone a laparoscopic cholecystectomy for acute cholecystitis 48 hours earlier. In the postoperative outcome, persistent abdominal pains and accentuated jaundice were observed. Abdominal ultrasonography showed stones in the common bile duct. The surgical history of the patient includes a two-third gastrectomy that was performed 10 years earlier for a T4 cancer of the transverse colon.
  • 01'08" Start of the procedure
    Endoscopy is carried out using an operative duodenoscope. It allows to identify that the patient had had a Billroth II distal gastrectomy with an isoperistaltic gastrojejunal anastomosis. Here you can see the duodenoscope coming from the efferent bowel loop towards the stomach; it is then pushed towards the afferent loop, which in the present case is orientated towards the greater curvature. Then we go into this long afferent loop. You can see the endoscope which forms a loop. Then, in order to perform a cholangiography, the endoscope must be withdrawn, tilted up until it reaches the second portion of the duodenum where quite unusually the papilla or Vater’s ampulla can be seen.
  • 02'06" Sphincterotome introduction
    We then use a normal sphincterotome. We reach the Wirsung’s canal first, and then the common bile duct by using a guide wire.
  • 02'43" Sphincterotomy and extraction of common bile duct stones
    Then the sphincterotomy may start, and you can see that in such a position, the ideal approach is to use an inverted sphincterotome. This can be obtained by unstretching the bow only. Here, by loosening the bow, the sphincter is finally cut whilst pushing towards the common bile duct. This is a totally different manoeuvre than the one that is usually performed. A guide wire is kept in place and since there are several big stones, we use a dilation balloon/catheter usually dedicated for colonic or esophageal stenosis in order to prepare for and ensure their extraction. This balloon will be dilated thanks to water mixed with contrast medium until 13.5mm so that the many 1cm stones can be extracted. Once the sphincterotomy opening has been dilated thanks to the balloon, a catheter with an extraction balloon is used to remove the stones one after the other and to obtain total emptying of the common bile duct. Here you can see another stone. The dilated extraction balloon catheter is approximately 15mm. You can see it coming out through the sphincterotomy opening. We therefore observe both the use of a normal sphincterotome that was inverted associated with a balloon dilator. Here you can see the end of the exploration. Thanks to the extraction balloon catheter, the common bile duct that was voided is filled up with contrast medium.
  • 06'05" Duodenoscope\'s removal
    You can see the duodenoscope being removed out of this loop that was mounted in an isoperistaltic fashion for a Billroth II gastrectomy.
  • Related medias
    This video presents the case of a 54-year-old patient who underwent a Billroth II distal gastrectomy 10 years ago with an isoperistaltic anastomosis and 48 hours before he had a laparoscopic cholecystectomy for acute cholecystitis. Because of persistent pain and accentuated jaundice related to choledocholithiasis, a large sphincterotomy was performed with a duodenoscope and a standard sphincterotome used as an inverted sphincterotome. A 13.5mm balloon dilation facilitated the extraction of several 1cm bile duct stones.