SLICE AND DICE - ENDOSCOPIC MANAGEMENT OF LARGE OBSTRUCTING INTRADUODENAL STONE USING ELECTROSURGICAL KNIFE

Background:
Two main reasons for a failed EUS- guided hepaticogastrostomy (EUS-HG) are, inability to access the bile ducts due to non-dilated intrahepatic ducts (IHD), and failure of tract dilation due to cirrhosis/ductal scarring or stent passage from misaligned vector forces. We present 5 cases that failed traditional EUS-HG, treated with EUS-rendezvous-HG.
RESULTS: 5 non-surgical patients, median age 52, (3 M) who failed conventional EUS-HG were treated successfully using 3 techniques. There were no adverse events over a median follow up of 28 months. (Tables 1 and 2)
Technique 1: EUS to IR balloon rendezvous. N=3.
Case 1: A 53 year old female with multiple surgeries and a Whipple procedure, presented with cholangitis and leakage around 2 long standing percutaneous biliary drains (PTBD) due to an afferent limb syndrome. EUS-HG into segment 2 failed to resolve the leak around the PTBD (in segment 3) not easily identifiable at EUS despite contrast injection. However, inflating an IR balloon allowed successful access and creation of an EUS-rendezvous-HG.
Technique 2: IR to IR rendezvous followed by endo-IR rendezvous. N=1.
Case 2: A 55 year old male with multiple comorbidities, prior Whipple procedure and R hepatectomy developed a perihepatic abscess from chronic dehiscence of his hepatico-jejunostomy. Having failed every other attempt to close this leak, an attempt was made for EUS-HG to divert bile from the leak site. Conventional EUS-HG failed due to non-dilated ducts as did an attempt to inflate an IR balloon. So, he underwent an IR to IR rendezvous. A peripheral branch of the L IHD closest to the gastric wall was accessed via the drain, dilated with a 4mm balloon, allowing opening of a loop snare. A transhepatic percutaneous needle puncture of this L IHD was then performed through the loop snare with subsequent puncture of the gastric lumen allowing placement of a guidewire and a successful rendezvous-HG.
Technique 3: EUS to Endo rendezvous. N=1.
Case 3: A 36 year old male with prior severe pancreatitis, benign biliary stricture, gastric outlet, and cirrhosis, had undergone a surgical gastrojejunostomy and hepaticoduodenostomy. He presented with recurrent cholangitis from food occluding his bile duct at the hepaticoduodenostomy (just proximal to the duodenal stricture). He had failed double pigtail biliary stents to keep the food out. So, he was taken for an EUS-HG to provide a more proximal diversion of his biliary tree. Although the L IHD was successfully punctured and a guidewire passed downstream, dilation of the tract failed due to dense scarring. However, after a successful rendezvous with the guidewire, we were able to create an EUS Rendezvous-HG in a retrograde fashion.
Conclusion:
When conventional EUS-HG fails, an EUS-rendezvous-HG with IR or oneself could successfully allow internal drainage rather than a long term PTBD.

Bouveret syndrome is a rare complication of cholelithiasis in which gallstone ileus occurs secondary to an acquired cholecysto-enteric fistula. The gallstone may migrate through the fistula and enter the gastrointestinal tract, causing gastric outlet obstruction. Given the rarity of the condition, there are no standardized treatment guidelines for the management of Bouveret syndrome.

We report a case of a 77-year-old male who presented to the emergency department with a 5-day history of gradual onset epigastric pain associated with nausea and vomiting after meals. His laboratory evaluation was significant for leukocytosis without left shift. Liver biochemistries were normal. Abdominal computed tomography (CT) demonstrated a large approximately 5cm calculus impacted in the proximal duodenum with marked gastric distention. The imaging findings confirmed the presence of a cholecysto-duodenal fistula with associated gastric outlet obstruction.

After multidisciplinary discussions involving surgical colleagues and considering patient preference, we proceeded with endoscopic management. During the endoscopy procedure, a large calculus was found wedged in the duodenal bulb immediately distal to the pylorus with near-total obstruction of the duodenal lumen. Extensive electrohydraulic lithotripsy was performed with delivery of over 15,500 pulses over the course of two prolonged procedures, yielding minimal fragmentation of the large stone. The decision was then made to utilize the submucosal dissection knife with electrosurgical energy. In a cautious and systematic method, stone fragmentation was performed by grasping the stone with the knife tip and delivering electrosurgical energy while retracting the knife into a distal attachment fitted onto our endoscope. Great care was undertaken to avoid mucosal contact and resultant bleeding. This approach yielded large stone fragments which were grasped and withdrawn into the stomach using a retrieval net and large-caliber snare.

After stone fragmentation and removal, a large cholesysto-duodenal fistula was identified with additional multiple large, pigmented stones visualized within the remaining gallbladder body. These stones were able to be retrieved into the stomach with a snare. Next, a 7Fr x 12cm double pigtail plastic stent was advanced antegrade into the duodenal lumen where it was deployed successfully. The proximal pigtail was placed within the gallbladder.

Our patient did well following the final procedure with minimal pain. He was subsequently reviewed by the surgical service and underwent laparoscopic cholecystectomy and fistula closure. Our case demonstrates that Bouveret’s syndrome, in particular gallstone fragmentation, was successfully managed utilizing a submucosal dissection knife with electrosurgical energy.Further evaluation is necessary before this approach can be widely accepted.