VHM06: Recurrent Bile Duct Stones

Abstracts acute cholecystitis with VRE and Candida septicemia. She was not a candidate for laparoscopic cholecystectomy or a radiologic cholecystostomy tube due to her decompensated cirrhosis (MELD score ⫽ 39). She was not a candidate for liver transplant due to persistent alcohol abuse. Due to persistent bacteremia, the decision was made to place a gallbladder stent for decompression. Endoscopic methods: During ERCP, her cystic duct could not be opacified by contrast injected through a sphincterotome or by an occlusion cholangiogram using a balloon catheter. A 10 French cholangioscope was introduced into the bile duct over a Jagwire. Starting from the bifurcation, the cholangioscope was withdrawn until cystic duct was identified by direct visualization. We then maneuvered a 0.035” glidewire through the cystic duct orifice and into the gallbladder using cholangioscopy and fluoroscopy. Once wire placement into the gallbladder was confirmed, a double pigtail stent was then successfully placed over the guidewire. Clinical implications: Peroral cholangioscopy during ERCP is a useful tool to aid with successful gallbladder stent placement.

VHM04 The Use of Fully Covered Metal Stents in the Treatment of Ampullary Adenomas Gonda TA, Bakhru M, Stevens PD, Kahaleh M Background: Endoscopic resection of ampullary adenomas is challenging and one of the reasons that curative resection may not be obtained results from the extension of adenomatous tissue into the common bile duct. There is limited expereince with the use of covered metal stents in the resection of ampullary adenomas. Endoscopic methods: These stents provide the advantage of removability and the potential to induce necrosis after tissue destruction by argon plasma coagulation. Covered metal stents are used initially to obtain better access to the bile duct epithelium. On a subsequent examination, after removal of the stent, snare resection and argon plasma coagulation is used. A second metal stent is then placed to assure biliary patency and potentially induce tissue necrosis.Clinical implications: After removal of the stents, in both cases biopsies have confirmed the absence of residual adenomatous tissue in the bile duct. Therefore we suggest that these stent may be particularly useful in the multistage resection of ampullary adenomas that extend into the bile duct.

VHM05 Direct Intraductal Electrohydraulic Lithotripsy Through an Enteroscope in Patients with Roux-en-Y Fernando Marson, Janak N. Shah, Andres Sanchez-Yague, Kenneth F. Binmoeller Background: Endoscopic management of cholelithiasis in patients with altered anatomy is challenging. More Roux-en-Y cases are expected in the bariatric surgery era. The full range of accessories used in standard ERCP are not available for enteroscopes. We report direct cholangioscopy-guided electrohydraulic lithotripsy (EHL) using two different push-pull enteroscopy platfoms for treatment of bile duct stones in patients with Roux-en-Y anatomy. Endoscopic methods: Push-pull enteroscopies were performed in two patients presenting with abdominal pain, elevated cholestatic liver enzymes, and abnormal MRCP revealing biliary stones. Case 1: Single balloon enteroscopy was used to reach the duodenum in a patient post gastric bypass. ERCP revealed a 1.5 cm stone. Stone extraction failed after sphinteroplasty, basket and balloon sweeps. Direct ductoscopy-guided EHL was performed using the enteroscope. Case 2: Double balloon enteroscopy was used to reach the anastomosis in a patient with hepaticojejunostomy after iatrogenic common bile duct injury. ERCP revealed multiple large impacted stones. Stone extraction maneuvers failed. Direct ductoscopy-guided EHL was performed using the enteroscope. Clinical implications: Direct cholangioscopy-guided electrohydraulic lithotripsy was performed using two platforms of push-pull enteroscopy (single- and doubleballoon) to achieve biliary access in patients with Roux-en-Y anatomy. Complete stone removal was achieved.

VHM06 Recurrent Bile Duct Stones Deepak Agrawal, Amitabh Chak Background: Multiple recurrences of bile duct stones are rare (2% patients). Suggested causes include bile stasis from bile duct strictures and nidus for stone formation from refluxed particulate food matter or stones. Rare causes include intrabiliary surgical clips and sutures. We demonstrate diagnosis and treatment of a case of recurrent stones due to suture material inside the bile duct using direct cholangioscopy. Endoscopic methods: ERCP (Endoscopic retrograde cholangiopancreatography), Cholangioscopy. Clinical implications: Intrabiliary sutures should be recognized as a cause of recurrent bile duct stones

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VHM07 Combined Cholangioscopy and Confocal Endomicroscopy of An Indeterminant Biliary Stricture Divyesh V. Sejpal, Kalpesh K. Patel Backgound: 48 year old male with a history of chronic alcohol abuse presented with painless jaundice. CT scan and EUS revealed biliary dilation without an associated mass lesion. Initial ERCP showed a CBD stricture, however cytology brushings were non-diagnostic. The patient was then then referred to our institution for ERCP with cholangioscopy for further management of this indeterminant biliary stricture. Endoscopic methods: ERCP with single operator cholangioscopy and probe based confocal endomicrsocopy. Clinical implications: The combination of ERCP with cholangioscopy and probe based confocal endomicroscopy may improve the diagnostic yield in patients with indeterminant biliary strictures.

VHM08 Endoscopic Treatment of Acute Arterial Bleeding During Pancreatic Necrosectomy George Rateb Background: The patient is 27 year-old male with history of heavy alcohol consumption, who developed walled-off pancreatic necrosis two months after a severe pancreatitis. Abdominal CT scan revealed a large necrotic cavity in the pancreatic body region with areas of blood density. Angiography was negative for vascular communication and pseudoaneurysms. Endoscopic methods: EEUS-guided sampling of the necrotic fluid revealed fungal infection. EUS-guided necrosectomy was performed. Transgastric puncture of the necrotic cavity with a 19G FNA needle. A tract was established using a cystotome. Balloon dilation was then done and the cavity was entered with a therapeutic gastroscope. Debridement of the necrotic cavity was done using endoscopic nets and baskets. A naso-biliary drain was left inside the cavity to keep the tract open and to allow lavage. One week later a second debridement session was performed. Suddenly red blood was seen trailing behind the endoscopic net. On immediately re-entering the cavity an arterial jet was seen. A clip was successfully placed and seemed to have stopped the bleeding. Four other clips were placed to ensure haemostasis. No significant rebleeding occurred. After a third debridement session, two pigtail stents were placed. Within three months the cavity near-completely disappeared and the stents were removed. The patient resumed his normal life. Clinical implications: Negative abdominal angiography may not exclude the presence of a significant blood vessel inside a necrosis cavity. In case of acute arterial bleeding inside the necrosis cavity endoscopic placement of clips could help to achieve haemostasis in selected cases.

VHM09 EUS-Guided Hepaticogastrostomy With a Transluminal Stent for Proximal Biliary Obstruction After a Failed ERCP Tae Jun Song, Do Hyun Park, Jung Je Cho, Jun Bum Eum, Sung-Hoon Moon, Sang Soo Lee, Dong Wan Seo, Sung Koo Lee, Myung-Hwan Kim Background: Endoscopic ultrasound(EUS)-guided hepaticogastrostomy may be a useful alternative method for patients with proximal biliary obstruction in whom endoscopic transpapillary biliary drainage failed. This case series was conducted to determine the feasibility and usefulness of EUS-guided hepaticogastrostomy technique for patients with proximal biliary obstruction when the endoscopic transpapillary drainage was unsuccessful. Endoscopic methods: The initial puncture was performed from cardia or lesser curvature of stomach toward dilated left intrahepatic duct with 19-gauge needle. After puncture, radio-contrast medium was injected to confirm successful biliary access, and a 0.035 inch guidewire was introduced through the EUS needle. Afterwards, 6F and 7F tapered, biliary, dilator catheters were inserted and removed over the guidewire to dilate the tract. In the case of resistance to the advance of 6F bougie catheter, a triple lumen needle knife was inserted over the guidewire to dilate the tract. Finally, fully covered selfexpandable metal stent or straight plastic stent was inserted through the guidewire. Clinical implications: EUS-guided hepaticogastrostomy with a transluminal stent may be technically feasible and can offer clinically effective drainage in selective patients with proximal biliary obstruction after a failed ERCP.

VHM10 A Self-Propelled Spiral Enteroscope With an Integrated Remote Control Motorized Spiral Paul A. Akerman, Daniel Demarco, Elizabeth Odstrcil, Jesus Pangtay Background: Deep small bowel enteroscopy is a challenging area of endoscopy despite improvements in technology. Spiral enteroscopy is a deep small bowel technique that uses an overtube to rotate a spiral to advance through the small bowel. Our hypothesis was that an enteroscope with an integrated remote control spiral could advance deeply into the small bowel without an overtube. Endoscopic methods: An enteroscope was constructed that was 160 cm long and 11.5 mm in diameter with an integrated remote

Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB103