Endoscopic ultrasound-guided transhepatic antegrade stone removal for choledocholithiasis after pancreaticoduodenectomy: A case report and review of literature

Abstract

BACKGROUND

The special choledocholithiasis (common hepatic duct stone) proximal to hepaticojejunostomy anastomosis following pancreaticoduodenectomy (PD) presents significant therapeutic challenges because of surgically altered anatomy, which precludes the use of conventional endoscopic retrograde cholangiopancreatography. Endoscopic ultrasound (EUS) offers a minimally invasive alternative for antegrade stone extraction. Here, we report a rare case of EUS-guided transhepatic antegrade stone removal (EUS-TASR) in a patient with choledocholithiasis occurring eleven years after PD.

CASE SUMMARY

A 58-year-old male with a history of PD for a duodenal tumor eleven years prior presented with a three-month history of intermittent upper abdominal discomfort. Imaging revealed a nodular filling defect in the common hepatic duct and mild intrahepatic biliary dilatation, confirming choledocholithiasis. Given the altered anatomy, endoscopic retrograde cholangiopancreatography was deemed unfeasible; thus, EUS-TASR with endoscopic nasobiliary drainage was successfully performed. The endoscopic nasobiliary drainage tube was removed on postoperative day 7, and the patient was discharged in stable condition on postoperative day 8. At the ten-month follow-up, the patient remained asymptomatic without complications.

CONCLUSION

EUS-TASR is a viable, minimally invasive approach for managing choledocholithiasis in post-PD patients with altered anatomy where conventional endoscopic access is restricted.

Key Words: Choledocholithiasis; Pancreaticoduodenectomy; Endoscopic ultrasound; Endoscopic ultrasound-guided transhepatic antegrade stone removal; Case report

Core Tip: Endoscopic retrograde cholangiopancreatography is often anatomically impossible for choledocholithiasis after pancreaticoduodenectomy. This case highlights endoscopic ultrasound-guided transhepatic antegrade stone removal as a highly promising minimally invasive solution. By enabling precise puncture and single-session stone removal through a transgastric approach in surgically altered anatomy, endoscopic ultrasound-guided transhepatic antegrade stone removal avoids the need for multiple procedures or complex surgery, positioning it as a potential first-line therapy in such patients. Further studies are warranted to standardize this advanced technique.

INTRODUCTION

Choledocholithiasis proximal to the hepaticojejunostomy anastomosis following pancreaticoduodenectomy (PD) is a rare but challenging benign biliary complication, often necessitating technically demanding endoscopic interventions or surgical revision of choledochoenterostomy[1,2]. Its pathogenesis involves multifactorial interactions stemming from surgically altered anatomy, with key contributors including hepaticojejunostomy anastomotic stricture, biliary stasis and altered biliary composition, local inflammation, retained foreign material, biliary duct dilation, preexisting biliary stones or chronic cholangitis, excessively long biliary segments or the formation of a pouch-like configuration and impaired ductal vascular supply[3-5].

Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for managing choledocholithiasis and enables simultaneous diagnosis and therapeutic stone extraction[6,7]. ERCP is typically precluded in post-PD patients because of altered anatomy, necessitating alternative approaches. Within the field of advanced endoscopy, endoscopic ultrasound (EUS) represents a minimally invasive and effective modality capable of both establishing an etiological diagnosis and facilitating therapeutic interventions in patients with surgically altered anatomy. Recent studies have highlighted EUS-guided techniques as effective minimally invasive approaches for planning Roux-en-Y anatomy interventions, such as jejunojejunostomy creation, metal stent apposition and biliary drain internalization[8-10]. Herein, we present a case report detailing EUS-guided transhepatic antegrade stone removal (EUS-TASR) performed using a transgastric approach in a patient who underwent PD with hepaticojejunostomy and who presented with common hepatic duct calculi.

CASE PRESENTATION

Chief complaints

A 58-year-old male with a three-month history of intermittent upper abdominal discomfort presented at our department.

History of present illness

Symptoms began three months prior to presentation with intermittent upper abdominal discomfort.

History of past illness

Eleven years ago, he underwent an open PD at our institution. Postoperative pathological examination revealed a benign duodenal tumor.

Personal and family history

His personal history included chronic alcohol consumption (100 mL/day for 40 years) and tobacco use (10 cigarettes/day for 40 years). The patient denied any family history of genetic diseases.

Physical examination

The following vital signs were recorded: Body temperature, 36.3 °C; blood pressure, 110/70 mmHg; heart rate, 78 beats per minute; and respiratory rate, 20 breaths per minute. Physical examination revealed mild tenderness in the upper abdomen.

Laboratory examinations

Laboratory tests revealed a white blood cell count of 14.96 × 10⁹/L, a neutrophil percentage of 94.8% and a procalcitonin concentration of 3.687 ng/mL. Other indicators, including hepatic function parameters, complete blood count and tumor markers showed no significant abnormalities.

Imaging examinations

Contrast-enhanced abdominal computed tomography revealed hyperdense foci in the common hepatic duct, indicating the presence of calculi (Figure 1A). Subsequent magnetic resonance cholangiopancreatography confirmed 7-mm filling defects in the common hepatic duct with mild intrahepatic ductal dilatation (Figure 1B).

Figure 1 Imaging confirmation of common hepatic duct stones following pancreaticoduodenectomy. A: Contrast-enhanced computed tomography image revealing a hyperdense focus within the common hepatic duct (yellow arrowheads); B: Magnetic resonance cholangiopancreatography demonstrating a filling defect in the common hepatic duct (yellow arrowheads) with mild intrahepatic ductal dilatation (orange arrowheads).

FINAL DIAGNOSIS

On the basis of these findings, the diagnosis was symptomatic common hepatic duct stones, warranting consideration of therapeutic endoscopic procedures or surgical intervention.

TREATMENT

EUS-TASR techniques, EUS-guided antegrade cholangiography

A linear-array scanning echoendoscope (EG-580UT; Fujiflim, Tokyo, Japan) was advanced to the gastric fundus. After confirming the absence of gastric fundus varices and the patency of the gastrointestinal anastomosis, an echoendoscope was used to scan the left lateral lobe of the liver, identifying a mildly dilated bile duct in segment S2 (diameter approximately 2.9 mm). A 19-gauge fine-needle aspiration needle (Boston Scientific, MA, United States) was used to puncture the selected S2 duct branch under EUS guidance, and bile was aspirated (Figure 2A). Cholangiography revealed mildly dilated intrahepatic bile ducts and a 0.7 cm hyperechoic nodule within the common hepatic duct. Notably, the contrast agent did not opacity the distal jejunum (Figure 2B). Subsequently, a 0.035-inch Zebra guidewire with a hydrophilic tip (Boston Scientific, MA, United States) was advanced into the left intrahepatic duct.

Figure 2 Procedural steps of successful endoscopic ultrasound-guided transhepatic antegrade stone removal. A: Puncture of a bile duct branch in segment S2 of the liver using a fine-needle aspiration needle; B: Cholangiography confirming mildly dilated intrahepatic bile ducts and a hyperechoic nodule (stone) within the common hepatic duct (yellow arrowheads); C: A needle knife is used to incise the gastric wall and the liver parenchyma to establish a hepatoenteric tract; D: The guidewire is advanced across the biliary-enteric anastomosis into the jejunum; E: Dilation of the created hepatoenteric tract; F: Sequential balloon dilation of the biliary-enteric anastomosis; G: The stone within the common hepatic duct (orange arrowheads) is dislodged and pushed into the jejunum using a retrieval balloon catheter (yellow arrowheads); H and I: Placement of a nasobiliary drainage catheter across the biliary-enteric anastomosis.

Dilation of the hepatoenteric tract and biliary-enteric anastomosis

After the fine-needle aspiration needle was withdrawn, a triple lumen needle knife (MicroKnife™ XL, 5.5F, Boston Scientific, MA, United States) was used over the guidewire to incise the gastric wall and the liver parenchyma (Figure 2C) to access the left hepatic duct lumen. The guidewire was then advanced across through the biliary-enteric anastomosis into the jejunum under manipulation with a sphincterotome (Figure 2D). The hepatoenteric tract created was dilated using 5-8.5F dilators (Cook Medical, IN, United States) (Figure 2E). The narrow biliary-enteric anastomosis was sequentially dilated by using 6 mm/7 mm/8 mm and 8 mm/9 mm/10 mm balloon dilatation catheters (CRE™ Wireguided, Boston Scientific, MA, United States) (Figure 2F).

Stone removal, nasobiliary tube implantation and removal

The stone within the common hepatic duct was successfully dislodged and pushed into the jejunum loop using a retrieval balloon catheter (9 mm/12 mm; Extractor™ pro XL; Boston Scientific, MA, United States) using repeated withdrawal and advancement maneuvers (Figure 2G). After complete stone removal, repeat cholangiography confirmed the absence of residual stones within the intrahepatic ducts. Finally, an 8.5F nasobiliary drainage catheter (Boston Scientific, MA, United States) was placed across the bilioenteric anastomosis over the guidewire (Figure 2H and I). The echoendoscope was then withdrawn, and the nasobiliary tube was properly secured.

Postoperatively, the patient received a three-day course of cefuroxime for infection prophylaxis, fluid replacement and continuous nasobiliary drainage (approximately 300 mL of bile per day). On postoperative day 7, cholangiography via the nasobiliary duct revealed no residual stones in the intrahepatic bile ducts and no significant stenosis at the biliary-enteric anastomosis site (Figure 3A). Subsequently, a duodenoscope was inserted into the stomach cavity, confirming the proper position of the nasobiliary tube (Figure 3B). The nasobiliary tube was then removed under direct vision, and meticulous endoscopic observation confirmed the absence of active hemorrhage or biliary leakage at the puncture site (Figure 3C). Hemostatic clips were applied to close the puncture site to ensure hemostasis (Figure 3D). The patient was discharged on postoperative day 8.

Figure 3 Postoperative cholangiographic findings and nasobiliary tube management. A: Cholangiogram obtained through the nasobiliary tube showing no residual stones or significant anastomotic stenosis; B: Endoscopic view confirming the correct positioning of the nasobiliary tube within the gastric cavity; C: Endoscopic observation after tube removal revealed no active bleeding or bile leakage at the puncture site; D: Application of hemostatic clips to secure the puncture site.

OUTCOME AND FOLLOW-UP

At the ten-month follow-up after EUS-TSAR, the patient remained free of complications such as upper abdominal discomfort, fever, recurrence of bile duct stones, and jaundice.

DISCUSSION

Choledocholithiasis following PD is a rare but clinically challenging complication, that occurs in approximately 2%-5% of patients within 5-15 years post-surgery[2]. Its development involves interconnected multifactorial mechanisms. Anastomotic strictures, which occur in 2%-11% of cases, initiate biliary stasis that promotes bacterial colonization and stone formation[11-13]. Biliary-enteric reflux exacerbates this process by facilitating ascending cholangitis and pigment stone deposition[14]. Ischemic injury at the hepaticojejunostomy site contributes significantly, leading to fibrotic scarring and impairing ductal clearance mechanisms[15]. Additionally, excessively long afferent limbs or pouch-like configurations above the anastomosis create sediment traps where debris accumulates[16]. In the present case, the patient exhibited several classic risk factors, including chronic inflammation at the anastomotic site, biliary-enteric anastomotic stricture and ischemic injury at the hepaticojejunostomy site following PD, all of which synergistically promoted stone formation.

The optimal therapeutic strategy for this case was determined by a multidisciplinary team comprising hepatobiliary surgeons, gastroenterologists, experienced endoscopists, diagnostic radiologists and ultrasound interventionalists. Surgical treatment for choledocholithiasis after PD, traditionally considered the traditional standard, is associated with significant trauma, slow recovery, and prolonged hospitalization. ERCP success rates are relatively low because of excessively long afferent limbs, dense adhesions preventing the duodenoscope from reaching the biliary anastomosis, and difficulty in identifying the narrow biliary-enteric anastomosis post-PD. Percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) requires sufficiently dilated intrahepatic bile ducts, repeated sinus tract dilation, and the insertion of a bile drainage tube, which can cause patient discomfort and bile leakage. Consequently, after comprehensive discussion, a EUS-guided intervention was considered an efficient solution for such anatomically complex scenarios. Specifically, EUS-TASR offers a minimally invasive, single-session therapeutic option with the advantages of minimal trauma, rapid recovery and low cost.

The successful implementation of EUS-TASR in this case demonstrated several innovative techniques. First, successful transgastric puncture of the mildly dilated left intrahepatic duct (segment II, 2.9 mm) was crucial and depended on exquisite puncture skills to precisely avoid the hepatic artery and portal vein branches, providing stable access and direct alignment with the stonebearing the common hepatic duct. Second, a meticulous dilation strategy involving gradual tract dilation (5F-8.5F) followed by sequential balloon dilation for biliary-enteric anastomosis (6-8 mm, then 8-10 mm) was employed to minimize ductal trauma. Third, for stone extraction, a 9-12 mm retrieval balloon enabled antegrade dislodgement and propulsion into the jejunum without lithotripsy, reducing procedural time and complexity. Finally, prophylactic nasobiliary tube placement across the anastomosis reduces the risks of postoperative bleeding, bile leakage, and biliary tract infection. Moreover, postoperative cholangiography via the nasobiliary tube confirmed the absence of residual stones and revealed the patency of the biliary-enteric anastomosis. A double pigtail stent was not placed because of the potential risks of stone recurrence, stent displacement, and the need for subsequent hospitalization for stent removal.

Post-PD choledocholithiasis can be managed using several approaches, each with distinct advantages and limitations. Conventional ERCP, although effective for normal anatomy, is often anatomically inaccessible after PD, resulting in low success rates (< 20%) and notable complication risks (10%-25%), such as perforation and pancreatitis[17-19]. PTCSL, although feasible, typically requires multiple sessions, imposes the burden of an external drain, and has risks of bleeding and infection (10%-30% complication rate)[20,21]. Surgical revision, although highly effective (> 90% success), is associated with significant morbidity (5%-20%), including anastomotic leakage and stricture recurrence, and often involves challenging reoperations[22,23]. In contrast, EUS-TASR has compelling advantages over conventional modalities. EUS-TASR offers a minimally invasive alternative with a high single-session success rate (85%-95%)[24], in contrast to the multi-stage requirement of PTCSL[25], and eliminates the physical discomfort burden and infection risks associated with long-term external percutaneous tubes[26,27]. Furthermore, its reported complication rates (8%-15%) are comparable to, and not higher than, those of surgical revision (5%-20%)[23,26] (Table 1). Clinically, our patient’s symptom-free status at ten-month follow-up aligns with published outcomes demonstrating durable resolution. Therefore, for post-PD patients, EUS-TASR’s minimally invasive nature, high success rate, and lower morbidity profile position it favorably over ERCP (largely inaccessible), PTCSL (multistage, external drain), and surgery (high morbidity).

Table 1 Comparative analysis of post-pancreaticoduodenectomy choledocholithiasis management strategies.

Method	Success rate	Major limitations	Complication rate	Ref.
ERCP	< 20%	Anatomical inaccessibility, long Roux limbs, adhesions	10%-25% (perforation, pancreatitis)	[17-19]
PTCSL	70%-88%	External drain burden, fistula risk, requires multiple sessions	10%-30% (bleeding, infection)	[20,21]
Surgical revision	> 90%	High morbidity/mortality (5%-15%), challenging reoperation	5%-20% (anastomotic leak, recurrent stricture)	[22,23]
EUS-TASR	85%-95%	Requires advanced expertise, limited right-duct access	8%-15% (bleeding, bile leak)	[24,25]

ERCP: Endoscopic retrograde cholangiopancreatography; PTCSL: Percutaneous transhepatic cholangioscopic lithotripsy; EUS-TASR: Endoscopic ultrasound-guided transhepatic antegrade stone removal.

Despite its promising results, EUS-TASR has several limitations. Primarily, the procedure demands exceptional technical expertise in both advanced EUS and therapeutic endoscopy, limiting its availability to specialized centers. Anatomically, transgastric access may prove challenging for right-sided duct systems, restricting its applicability in some cases. With respect to durability, long-term data beyond one year remain limited, leaving recurrence rates incompletely defined[28,29]; therefore, regular and long-term follow-up is necessary. In terms of the limitations of our report, this is a single-center, single-case study; moreover, the 10-month follow-up period is relatively short for assessing stone recurrence and anastomotic patency in this case. However, we have a well-structured follow-up plan for continuously monitoring the prognosis in the patient. Nevertheless, several future innovations hold promise for expanding its utility. Specifically, lumen-apposing metal stents provide sustained fistula patency for repeated access, whereas EUS-guided percutaneous transhepatic biliary drainage approaches might overcome anatomical constraints for right-sided stones[30,31]. Additionally, dedicated devices for antegrade lithotripsy and improved navigation systems could further increase technical success.

CONCLUSION

In conclusion, EUS-TASR is a highly promising approach for managing choledocholithiasis in the context of surgically altered anatomy. By enabling transgastric access and facilitating antegrade instrumentation, EUS-TASR effectively circumvents the fundamental limitations of ERCP, PTCSL and surgical revision. This case reinforces its emerging role as a potential preferred therapy in post-PD patients with biliary stones, warranting prospective multicenter trials to standardize techniques and rigorously evaluate long-term outcomes.

ACKNOWLEDGEMENTS

The authors express their sincere gratitude to the patient and his family for their support.