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Bile duct stones are routinely removed during endoscopic retrograde cholangiopancreatography (ERCP) with biliary sphincterotomy, using standard balloon or basket extraction techniques. However, in approximately 10%–15% of patients, bile duct stonesmay be difficult to remove owing to challenging access to the bile duct, large bile duct stones (>15mm in diameter), intrahepatic stones, or impacted stones in the bile duct [1–3]. In such cases, an alternative procedure to ensure biliary drainagemay bewarranted. A 65-year-old manwas admitted for acute cholangitis with multiple organ dysfunction. Upper abdominal ultrasound showed a dilated common bile duct (CBD, 17mm), containing multiple stones. After hemodynamic stabilization and the initiation of antibiotic therapy, the patient underwent emergency ERCP. A pyloric and duodenal bulb deformation was noted, which prevented stabilization of the duodenoscope after CBD cannulation. Sphincteroplasty was performed using a large balloon, dilating the sphincter to 17mm (●" Fig.1), without prior sphincterotomy. A pediatric colonoscope was then advanced slowly into the CBDover a catheter, allowing its entry into the biliary tract. Multiple biliary stones were seen under direct visualization, the largest of which was 16mm. The largest stone could not be removed using a basket because of its size and position (●" Fig.2). Therefore, a Roth Net (US Endoscopy, Mentor, Ohio, USA) retriever was used. Under direct visualization, the Roth Net was opened, and easily captured the largest stone, which was removed without fragmentation (●" Fig.3a,b,c). The remaining small biliary stones and sludge were removed using a balloon. After the procedure, complete stone removal was confirmed by direct visualization (●" Fig.4). The procedure was performed using carbon dioxide insufflation. The patient was discharged 1 week later. Peroral cholangioscopy allows therapeutic procedures in the biliary tract under direct visualization [4]. In the present case, a novel retrieval method, which used an accessory that is widely available, was used to remove a difficult bile duct stone.

Peroral cholangioscopy: use of a Roth Net retriever for difficult biliary stones