performed data extraction and risk assessments. Michael K Dougherty performed data analysis and co-wrote the paper with Robert D Dorrell. Elizabeth T Jensen and Steven B Clayton provided oversight of the study. All authors contributed to the conceptualization of the study, interpretation of study results, and editing of manuscript drafts.
A 68-year-old woman with history of Roux-en-Y gastric bypass surgery and cholecystectomy presented with cholangitis. Six months prior to presentation, she was admitted to an outside hospital with gallstone pancreatitis and managed with percutaneous transhepatic biliary drainage. Her clinical course was complicated by proximal migration of a self-expandable metal stent (SEMS) placed for a distal bile duct stricture and recurrent cholangitis due to residual intrahepatic and extrahepatic stone disease. After discussion with the patient regarding treatment options, she underwent an endoscopic ultrasound-guided hepaticogastrotomy (EUS-HG) for biliary drainage. 1 A month later, patient returned for endoscopic retrograde cholangiography to facilitate stricture dilation, stones removal, and stent retrieval. A direct peroral antegrade cholangioscopy was performed via the HG tract using a 5.4 mm upper endoscope (Pentax, Tokyo, Japan). The left hepatic stones were visualized and fragmented with electrohydraulic lithotripsy (EHL; Fig. 1). Attempts to advance the endoscope into the common bile duct were unsuccessful due to sharp angulation of the left hepatic duct close to the confluence. Following retrograde removal of bile duct and left hepatic duct stone fragments with balloon sweeps, cholangioscopy was performed using SpyScope DS (Boston Scientific, Marlborough, MA, USA) with visualization of the distal bile duct stricture. Biopsies obtained from the stricture were benign. Next, under fluoroscopic guidance, the metal stent was captured with an Acusnare (Cook Medical, Bloomington, ID, USA) and removed in a retrograde fashion through the hepaticogastrostomy tract. The distal biliary stricture was dilated to 10 mm using a biliary dilating balloon. An 8 mm 9 80 mm SEMS was placed in the hepaticogastrostomy tract and anchored by a 7-Fr by 18 cm double pigtail stent (Fig. 2). To our knowledge, this is the only reported case of migrated SEMS retrieval through HG and one of few cases of hepatolithiasis treated with EHL through HG. 2,3 Authors declare no Conflict of Interests for this article.
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