A tough scope to swallow: endoscopic retrograde cholangiopancreatography through percutaneous endoscopic gastrostomy

Abstract

We are presenting a case of oral cancer with choledocholithiasis that was successfully treated with transgastric endoscopic retrograde cholangiopancreatography (ERCP). A 76-year-old female with past medical history of squamous cell cancer of the oral cavity status post hemiglossectomy with left anterolateral free flap, bilateral neck dissections, tracheostomy, and decannulation with gastrostomy tube placement, chemotherapy and radiation therapy presented with epigastric pain for 5 days. She experienced pain was radiating to the right upper quadrant and right flank, which was associated with nausea. Her vital signs were stable. Abdominal examination showed positive Murphy's sign; 18-French (Fr) gastrostomy tube was present in left upper quadrant.Laboratory tests revealed normal white blood cell count, with mildly elevated liver enzyme levels as follows: aspartate transaminase, 70 U/L; alanine transaminase, 105 U/L; alkaline phosphatase, 325 U/L; total bilirubin, 4.3 mg/dL; and direct bilirubin, 3.8 mg/dL. Computed tomography (CT) of the abdomen and pelvis revealed irregular gall bladder wall thickening, large calcified gall stones, intra and extra hepatic biliary duct dilation, and common bile duct diameter of 1.1 cm. An endoscope (Olympus) was inserted via the oral route, but the esophageal lumen could not be visualized. Subsequently, an adult endoscope was inserted through the gastrostomy. The insertion of scope was resistance-free. On retrograde view, the gastroesophageal junction was visualized and the view of upper esophagus was totally obstructed. Rendezvous procedure was attempted to reestablish the lumen connection from the esophagus to the hypopharynx but was unsuccessful. The scope was advanced to the duodenum, and the ampulla was visualized. An 18×20-mm esophageal stent (Cook Evolution fully covered stent) was advanced to the stomach with the help of previously placed guide wire under fluoroscopic visualization (Figure 1), 18-20-mm balloon dilator was inserted through the stent, and dilation was performed. A duodenoscope was inserted with gentle pressure and passed through the stent; the scope was advanced to the duodenum. A blush of bile and pus and the ampulla were identified. Biliary cannulation was performed using the wire-guided technique. Cholangiogram revealed a large stone at the cystic duct and a smaller filling defect at the distal common bile duct (CBD) ( Figure 2). Sphincterotomy was performed, and a 12-15-mm extractor balloon was advanced over the guidewire into the biliary tree. Balloon sweeps were performed, and a large stone was removed. Contrast, bile, and pus were draining from the biliary tree. Multiple balloon sweeps were performed, and the balloon could sweep through the papilla without resistance. An occlusion cholangiogram showed that the cystic duct stone had migrated toward the gallbladder. The balloon was removed, and a 10-F×9-cm plastic stent was placed into the CBD over the guidewire. The duodenoscope was withdvrawn. A 38-Fr gastrostomy tube (Malecot tube) was then placed t...

“Orphaned” Stomach—An Infrequent Complication of Gastric Bypass Revision

“…Instead, sinogram under fluoroscopy allowed visualization of the target for stenting and assessment of the tissue bridge to be traversed. Use of retrograde endoscopy via a gastrostomy site has been conducted before [29][30][31][32]. In such cases, it is important to allow the gastrostomy site to mature, such that the stomach is adherent to the anterior abdominal wall.…”