title: Endoscopic ultrasound-guided anterograde treatment of biliary stones following gastric bypass.
abstract: Endoscopic treatment of bile duct stones in gastric bypass patients is challenging. We describe a novel method involving endoscopic ultrasound (EUS)-guided anterograde interventions. After prior experience with EUS-guided rendezvous endoscopic retrograde cholangiopancreatography (ERCP) and direct EUS-guided anterograde stenting for malignant biliary obstruction, we have attempted EUS-guided treatment of biliary stones as first-line therapy following gastric bypass. Our approach involves: (i) EUS-fine needle aspiration (FNA) puncture into an intrahepatic bile duct; (ii) EUS-guided cholangiography; (iii) guide wire advancement across the ampulla; (iv) catheter dilation of the transhepatic-transgastric access tract; (v) anterograde balloon sphincteroplasty; and (vi) anterograde advancement of stones across the ampulla using a balloon catheter. We reviewed outcomes and complications of this technique. Six patients with previous Roux-en-Y gastric bypass were referred for treatment of symptomatic choledocholithiasis. EUS-guided transhepatic puncture and cholangiography was successful in 100 %, and revealed choledocholithiasis in all patients. Tract dilation, anterograde balloon sphincteroplasty, and stone extraction were successful in four (67 %). Anterograde sphincteroplasty failed in two patients due to inability to advance the transhepatic dilation catheters. In both cases, wires were advanced down the afferent limb, and rendezvous ERCP using double-balloon enteroscopy was successful. Five patients experienced no complications. One patient in whom EUS anterograde therapy failed due to difficulty in advancing the transhepatic dilation catheter, developed a subcapsular hepatic hematoma. This was managed conservatively. Direct EUS-guided treatment of biliary stones after gastric bypass appears safe and feasible. Further studies are needed to confirm the safety and efficacy of this technique.
authors: Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California 94115, USA.
authors: F
authors: F
authors: Weilert
authors: K F
authors: KF
authors: Binmoeller
authors: F
authors: F
authors: Marson
authors: Y
authors: Y
authors: Bhat
authors: J N
authors: JN
authors: Shah
mesh_terms: D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde; D042883:Choledocholithiasis / Q000175:diagnosis / Q000628:therapy*; D019160:Endosonography; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery; D016717:Sphincterotomy, Endoscopic; D018084:Ultrasonography, Interventional