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This is the case of an 85-year-old woman with a distant history of cholecystectomy and complicated bile duct stone disease who had undergone several endoscopic retrograde cholangiography (ERC) procedures including standard-incision papillotomy elsewhere, and was now undergoing repeat ERC after resolution of an episode of acute cholangitis. Because of a complicated ERC anatomy, fluoroscopy provided limited information as to the location of the stone; basket capture was unsuccessful (▶Fig. 1). With the patient still receiving piperacillin/tazobactam antibiotic treatment, we therefore proceeded to diagnostic direct cholangioscopy after freehand intubation using an ultraslim endoscope (GIF XP160; Olympus, Hamburg, Germany; outer diameter 5.9mm, working channel 2.0mm) [1], unequivocally identifying a cystic duct remnant stone, which was confirmed by cholangioscopy-directed injection of contrast media (▶Fig. 2). Biliary insertion of a standard-sized upper gastrointestinal endoscope was precluded because of an insufficiently large papillotomy opening; therefore, endoscopic papillary large balloon dilation (EPLBD; CRE Balloon Dilation Catheter, Video 1: In light of equivocal findings on endoscopic retrograde cholangiography (ERC), we first performed diagnostic (ultraslim) direct cholangioscopy in freehand fashion to identify a giant stone in the markedly dilated cystic duct remnant, and subsequently used balloon dilation-assisted therapeutic (standard size) direct cholangioscopy with cholangioscopy-facilitated mechanical lithotripsy to complete stone clearance. ▶ Fig. 1 Endoscopic retrograde cholangiography (ERC) image (mixed spontaneous air and dye cholangiogram) in the long axis provides limited information because of reduced maneuverability owing to a deep papilla location at the 3 o’clock position of a periampullary diverticulum. A large stone (25mm in diameter) is seen, but its position is equivocal because of an overlying grossly dilated low-inserting cystic duct remnant. ▶ Fig. 2 Direct cholangioscopy was performed using an ultraslim upper gastrointestinal endoscope (note: neither CO2 insufflation nor saline instillation was needed, given the markedly dilated biliary system). a Direct cholangioscopy view showing a stone in the cystic duct remnant. b Fluoroscopic image after cholangioscopy-guided contrast injection confirming the stone to be located in the hugely dilated cystic duct remnant. E-Videos

endoscopy

A “tandem approach” using sequential diagnostic (ultraslim) and therapeutic (standard size) direct freehand cholangioscopy to guide mechanical lithotripsy of a giant cystic duct remnant stone