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In the management of biliary stones, transpapillary stone extraction during endoscopic retrograde cholangiopancreatography (ERCP) has been established as the standard treatment [1]. The procedure is occasionally difficult, especially in cases with benign stricture of the duodenum caused by groove pancreatitis [2]. Stone extraction under percutaneous transhepatic biliary drainage and surgery are conventionally performed as alternative methods after unsuccessful ERCP [3]. However, both methods are invasive and reduce patients’ quality of life. Here, we present a successful case of biliary stone extraction achieved via creation of a neo papilla (▶Video1). A 78-year-old man underwent gastrojejunostomy for the duodenal stricture associated with groove pancreatitis and later developed obstructive jaundice due to biliary stone (▶Fig. 1). An attempted ERCP failed due to an inaccessible papilla. A neo papilla was created at the duodenal bulb by endoscopic ultrasound-guided choledochoduodenostomy with plastic stent placement to decompress the bile duct (▶Fig. 2). Biliary stone extraction was then attempted 1 month later via the neo papilla. The plastic stent was removed using a stent retriever (Soehendra Stent Retriever; Cook Medical, Bloomington, Indiana, USA) and a cholangiogram confirmed the existence of the stone. The neo papilla was dilated up to 8mm using a balloon catheter (ZARA; Century Medical, Tokyo, Japan) (▶Fig. 3). The stones were then crushed using a mechanical lithotripter (XEMEX Crusher Catheter; Zeon Medical, Tokyo, Japan), and stone fragmentswere successfully removed though the neo papilla (▶Fig. 4, ▶Fig. 5). A nasobiliary drainage tube was then placed in the bile duct to wash away the small residual stone fragments. No adverse events occurred for the patient. Extraction of biliary stones via a created neo papilla appears to be safe and achievable, because thematured fistula allowed the use of larger devices [4]. This technique may be a feasible alternative to rescue transpapillary stone extraction in patients with benign stricture of the duodenum.

A rescue approach using a neo papilla for choledocholithiasis in patient with benign duodenal stricture