IJGII Inernational Journal of Gastrointestinal Intervention

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Case Report

Int J Gastrointest Interv 2022; 11(4): 192-196

Published online October 31, 2022 https://doi.org/10.18528/ijgii220006

Copyright © International Journal of Gastrointestinal Intervention.

Per-oral cholangioscopy via a gastric access loop for the management of recurrent hepatolithiasis

Sneha Lad1 , Suryaprakash Bhandari2,* , Hardik Rajesh Shah2 , Nilesh Doctor1 , Roy Patankar1 , and Smita Bhandari2

1Department of Digestive Diseases, Zen Multispeciality Hospital, Mumbai, India
2Gastrocare Centre of Excellence for Advanced Gastrointestinal Endoscopy and Endoscopic Surgery, Mumbai, India

Correspondence to:*Gastrocare Centre of Excellence for Advanced Gastrointestinal Endoscopy and Endoscopic Surgery, J.N. Road, Mulund (West), Mumbai 400080, India.
E-mail address: drsurya_b@yahoo.com (S. Bhandari).

Received: February 11, 2022; Revised: May 11, 2022; Accepted: June 23, 2022

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

This is a case report of the successful management of recurrent large intrahepatic stones using per-oral cholangioscopy via a gastric access loop created surgically during Roux-en-Y hepaticojejunostomy (HJ). A 55-year-old male presented with acute cholangitis. Radiodiagnostic imaging suggested hepatolithiasis in the left hepatic duct. He had experienced similar events on three occasions in the past, for which preliminary conventional endoscopic retrograde cholangiopancreatography and percutaneous transhepatic biliary drainage approaches proved only supportive. Hence definitive surgical treatment was performed with the patient's consent during his third admission in the form of cholecystectomy, intraoperative retrieval of hepatolithiasis using a rigid ureteroscope, and Roux-en-Y HJ with gastric access loop formation. The gastric conduit facilitated prompt and convenient endoscopic access to enter the intrahepatic ducts and achieve complete ductal clearance using cholangioscopy-guided laser lithotripsy of the large intrahepatic stones. The patient remained asymptomatic at subsequent follow-up visits.

Keywords: Anastomosis, Roux-en-Y, Calculi, Cholangitis, Jaundice, Lasers

Hepatolithiasis (HL) refers to the presence of calculi within the intrahepatic bile duct proximal to the joining of the right and left hepatic duct. It is a serious condition, as it predisposes patients to repeated cholangitis episodes, recurrent intrahepatic stone formation at other sites, secondary biliary cirrhosis, liver failure, and eventually death.1 No predefined algorithm exists for the treatment of HL, and a multimodal approach is required. Multiple treatment options have been described, including endoscopic, percutaneous, and surgical interventions. A recent trend has been the re-emergence of Roux-en-Y hepaticojejunostomy (HJ) as a promising surgical technique over hepatectomy.2 Postoperative biliary stricture, recurrence of HL, or both at the anastomotic site are common late complications of HJ.3 Endoscopic entry or re-operation of a strictured HJ is technically difficult and hazardous, especially in the setting of long-term sequelae such as secondary biliary cirrhosis with portal hypertension, atrophy of liver lobes, and cholangitic liver abscess.4 Modifications of HJ with access loop formation in the form of a subcutaneous, duodenal, or gastric conduit is now favoured to facilitate endoscopic entry for anastomotic stricture dilatation or residual intrahepatic stone retrieval. In our case, we used an ultrathin gastroscope to enter via a gastric conduit and access the stones located in the left intrahepatic ducts through a Roux-en-Y HJ limb for laser lithotripsy.

A 55-year-old man presented with fever, upper abdominal pain, and jaundice that had lasted for 3 days. At the time of admission, he was icteric, afebrile, normotensive (blood pressure: 110/70 mmHg) with mild tachycardia (pulse: 96 bpm), and maintained oxygen saturation on room air (SpO2: 97%). The laboratory parameters were suggestive of elevated inflammatory markers (C-reactive protein, 55 mg/L), leucocytosis (white blood cell count: 18,000/mm3, N: 80%) and deranged liver function tests (total bilirubin: 5.3 mg/dL, alanine aminotransferase: 146 U/L; aspartate aminotransferase: 172 U/L, alkaline phosphatase: 296 IU/L). Abdominal ultrasonography was suggestive of dilated intrahepatic biliary radicles with wall thickening and multiple calculi predominantly in the left lobe of the liver. Magnetic resonance cholangiopancreatography confirmed the ultrasound findings (Fig. 1).

Figure 1. Magnetic resonance cholangiopancreatography showing intrahepatic stones (arrow) in the left liver lobe.

In the past, the patient suffered similar episodes of biliary obstruction secondary to intrahepatic stones and cholelithiasis complicated with acute cholangitis. During the index event, which occurred approximately 4 years previously, the patient urgently required endoscopic retrograde cholangiopancreatography (ERCP) for biliary drainage to manage sepsis. However, the intrahepatic stones could not be retrieved with ERCP. Subsequently, in less than a month, due to biliary stent blockage, the patient’s clinical status worsened, with recurrence of symptoms and rapid development of cholangitic abscesses in bilateral liver lobes. Hence, the biliary stent was removed and he underwent percutaneous transhepatic biliary drainage (PTBD) with computed tomography-guided percutaneous pigtail catheters inserted in both lobes to drain the cholangitic abscesses (Fig. 2). However, the patient was then lost to follow-up for approximately 3 years and presented again with a repeated episode of cholangitis, for which he again underwent PTBD. He received counselling regarding definitive surgical treatment and later underwent cholecystectomy, intra-operative retrieval of intrahepatic calculi using a rigid ureteroscope, and Roux-en-Y HJ with formation of a gastric access loop (Fig. 3)

Figure 2. Abdominal computed tomography with a pigtail catheter and percutaneous transhepatic biliary drainage stent in situ for drainage of the cholangitic abscess and for biliary drainage, respectively (arrows).
Figure 3. Diagrammatic representation of hepaticojejunostomy with a gastric access loop.

In the present admission, which occurred almost 6 months after surgery, the patient underwent a per oral endoscopic intervention for the removal of the intrahepatic stones. With per oral use of an ultrathin gastroscope (GIF-XP 170N; Olympus, Tokyo, Japan), the scope was negotiated across the gastric access loop (Fig. 4) and via the HJ anastomotic site into the left secondary intrahepatic ducts. Under direct vision, the intrahepatic stones (Fig. 5) were pulverised using a holmium laser (Fig. 6) and extracted using a stone extraction basket and balloon. This process was carried out under fluoroscopy guidance (Fig. 7, 8). The patient’s condition improved symptomatically after the procedure, and complete biochemical recovery occurred within 2 weeks. At a subsequent follow-up visit after 3 months, a repeat cholangioscopy to check for recurrence confirmed complete clearance (Fig. 9). The patient’s general condition has remained stable to date.

Figure 4. Endoscopic image of the gastric access loop.
Figure 5. Hepatolithiasis in the left intrahepatic duct.
Figure 6. Laser lithotripsy of intrahepatic stones.
Figure 7. Fluoroscopic image showing sludge and stones in left ductal system (arrow).
Figure 8. Fluoroscopic image showing clearance of the ductal stone.
Figure 9. Ductal clearance of left intrahepatic ducts.

The causes of HL are either primary or secondary due to biliary strictures, sclerosing cholangitis, cholelithiasis, choledocholithiasis, repeated bacterial infections, altered biliary anatomy, or congenital bile duct anomalies. The disease is endemic in the Asia-Pacific region, where its prevalence can be as high as 30% to 50%.5 The rate is around 2% to 25% in East Asian countries and approximately 1% in the West.6,7 The left hepatic duct is the most frequent site of stone occurrence (estimated to be as high as 78%), possibly because it joins the common hepatic duct at an acute angle, causing bile stasis. Left unilateral disease involvement is seen in approximately 35% to 50% of cases.8 The available endoscopic interventions are endoscopic ERCP, per oral cholangioscopy lithotripsy, and percutaneous transhepatic cholangioscopic lithotripsy. Management with ERCP can be technically difficult due to strictures, ductal angulation, inaccessibility, or the degree of stone impaction. Failed preliminary conventional endoscopic interventions and recurrent cholangitis warrants surgery, as in our case. Hepatectomy and HJ are the surgical options in practice, of which HJ is preferred, although partial hepatectomy remains the gold-standard treatment.9 Modifications of HJ with the creation of an access loop in the form of a subcutaneous, duodenal, or gastric conduit to facilitate endoscopic or fluoroscopic entry for HJ stricture dilatation and intrahepatic stone retrieval have been described in the literature. However, the percutaneous approach has lost favor due to limitations, such as pain at the stoma site, bile discharge causing skin excoriation, infection, fistula formation, and incisional hernia. The hepatic-jejuno-duodenal access loop, since its introduction in 1991 by Stiegmann et al,10 has been a valuable modified reconstruction technique rendering future endoscopic access in intrahepatic ducts for other indications besides the management of HL.11 Similarly, five major case series (Table 1) have been reported to date in the literature, emphasising bilio-enteric gastrostomy (i.e., a gastric access loop) as a useful adjunct in dealing with the postoperative complications of HJ.1216 However, only three of those studies demonstrated the actual therapeutic use of gastric loops to facilitate endoscopic therapy: Perakath et al14 described the utilisation of gastric access for successful endoscopic stricture dilatation in two patients who developed HJ occlusion; Jayasundara et al15 reported the largest case series, presenting their experience with 27 patients, and restated the benefits of HJ with a gastric access loop and demonstrated its therapeutic significance in three patients, of whom two required stricture dilatation at the anastomotic stricture site and one was managed with balloon sweep for HL; and Hamad and El-Amin16 performed bilio-enteric-gastrostomy in all 17 patients presenting with benign biliary stricture, of whom only one developed HJ stricture requiring access for endoscopic therapy via a gastric loop. There have been no head-to-head comparisons regarding the preference of a duodenal access loop versus a gastric access loop, and the choice of conduit largely depends on the surgeon’s predilection given the clinical case-based scenario. Per oral cholangioscopic treatment of HL was first described by Okugawa et al17 in 2002 and has been in clinical use since then. Our case vignette reflects a unique multi-disciplinary experience in the approach to the management of recurrent HL. Interestingly, the gastric access loop laid a convenient path of easy entry for the ultrathin gastroscope to reach across the anastomotic site of HJ into the left intrahepatic ducts for successful laser lithotripsy of HL. We emphasise the importance of a gastric conduit during Roux-en-Y HJ to enable proficient endoscopic access and the utility of per oral cholangioscopy as a tool to conduct interventions for IHS and strictured HJ.

Table 1 . Summary of Case Series on Gastric Access Loops.

AuthorTotal no. of casesNo. of cases followed upPeriod of follow up (mo)ComplicationTherapeutic use of gastric access loop
Sitaram et al12 (1998)1073–24Hepaticojejunostomy stricture-1
Asymptomatic gastrojejunostomy ulcer-1
Perakath et al14 (2003)8Specific data not availableSpecific data not availableHepaticojejunostomy stricture-2Stricture dilation-2
Selvakumar et al13 (2008)131120–81 (mean = 51)Hepaticojejunostomy stricture-1
Gastrojejunostomy stricture-3
Jayasundara et al15 (2010)27256–61 (mean = 35.4)Hepaticojejunostomy stricture-3Stricture dilation-1
Stricture dilation and stenting-1
Balloon sweeping-1
Hamad and EI-Amin16 (2012)17167–35 (mean = 23)Hepaticojejunostomy stricture-1Stricture dilation and stenting-1

Perakath et al14 discusses need of portosystemic shunting before hepaticojejunostomy in patients with portal hypertension following iatrogenic biliary injuries and separate data on follow up of gastric access loop patients was not available..

No potential conflict of interest relevant to this article was reported.

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