Role of Direct Peroral Cholangioscopy in Difficult Biliary Stones: A Case Report

The authors report the case of a 76-year-old female with a medical history of liver transplant in 1991 for primary biliary cholangitis, which was complicated with an anastomotic stricture. She had previously been submitted to 4 endoscopic retrograde cholangiopancreatography (ERCP) procedures (between 2009 and 2016), including 2 direct peroral cholangioscopies (POC) [1], due to episodes of symptomatic choledocholithiasis/cholangitis. In the last procedure, balloon catheter passage and POC with mechanical lithotripsy failed to remove the largest stone, and a plastic stent was placed to permit biliary drainage and promote partial stone fragmentation (Fig. 1). Three months later, POC was repeated with a conventional videogastroscope (Olympus® GIF-Q180), with identification of a biliary stone at the anastomosis (Fig. 2), which was removed with a Roth Net®. A cholangiogram confirmed the persistence of a subtraction defect of 20 mm, proximal to the anastomosis. Mechanical lithotripsy (Olympus® BML-110 Mechanical Lithotriptor) was attempted without success. Then, anastomosis dilatation up to 15 mm (Boston Scientific® CRE Wireguided Balloon Dilation) was performed, under direct and fluoroscopic control. Subsequently, the conventional endoscope was introduced proximal to the anastomosis with direct visualization of the calculus, which was successfully removed recurring to a polypectomy snare (Olympus® SnareMaster) (Fig. 3). The final cholangiogram revealed no subtraction defects, with proper biliary drainage. Benign biliary strictures are mostly related to liver transplantation or chronic pancreatitis [2]. Benign biliary strictures are mostly related to liver transplantation or chronic pancreatitis [2]. In fact, anastomotic strictures are one of the most common adverse events after liver transplantation, occurring in up to 34% of cases, being more common in transplants with living liver donors [3]. In the recent years, endoscopic treatment with balloon dilation or biliary stent has become the gold standard, and surgical intervention is reserved for unsuccessful or inaccessible strictures to endoscopic treatment [3]. Even though the optimal endoscopic strategy for the treatment of these strictures remains to be defined, in a recent metaanalysis, Aparício et al. [3] concluded that the endoscopic treatment of anastomotic strictures with fully covered self-expandable metal stents was equally effective as the treatment with plastic stents, but the former was associated with a lower complication risk. Also, the use of sin-