Management of biliary stones in patients with surgically altered anatomy (SAA) remains challenging due to the limited endoscopic access to the biliary tree. Enteroscopy-assisted ERCP may fail even in expert hands, and alternative approaches such as percutaneous transhepatic access or surgical revision carry significant risks and morbidity.
We report the case of a young patient with SAA and a large impacted stone at the hepatic duct confluence. Enteroscopy assisted ERCP failed due to inability to reach the anastomotic site. A safe and minimally invasive strategy was required to access, fragment, and clear the biliary stone while avoiding additional surgical morbidity.
We adopted a three-stage endoscopic strategy combining interventional EUS and Cholangioscopy. EUS-guided Hepatico-Gastrostomy (EUS-HGS) was performed followed by antegrade digital transhepatic cholangioscopy, and then a modified wire-guided cholangioscopy technique that ultimately enabled successful laser lithotripsy and stone clearance.
A)Stage 1 – EUS-guided Hepatico-Gastrostomy
Under linear EUS guidance, the left intrahepatic bile duct was punctured from the gastric body.
A guidewire was advanced antegrade across the obstruction. A 7Fr Cystotome was inserted in the tract.
A partially-covered self-expandable metal stent (PC-SEMS) was deployed, establishing a stable hepatico-gastric fistula.
This provided a secure transluminal route for subsequent cholangioscopy.
B)Stage 2 – Antegrade Digital Cholangioscopy
A digital cholangioscope was advanced through the HGS stent to reach the biliary confluence. However, due to the sharp angulation created by the metallic stent, the scope could not be maneuvered sufficiently to access the bile duct. As a result, laser lithotripsy could not be performed at this stage, and an alternative strategy was required to optimize access and achieve ductal clearance.
C)Stage 3 – Wire-Guided Cholangioscopy after Stent Removal
The PC-SEMS was removed to straighten the tract and reduce the angulation. A sphincterotome with a guidewire was then carefully advanced antegrade into the bile duct. The digital cholangioscope was subsequently railroaded over the guidewire, which provided a stable and aligned path through the hepatico-gastric tract.This maneuver allowed successful advancement of the cholangioscope into the common bile duct, where the large biliary stone was directly visualized. Laser lithotripsy was performed, fragmenting the stone into small pieces, and routine antegrade extraction maneuvers with basket and balloon allowed complete ductal clearance.
The three-stage procedure was completed without complications. EUS-HGS provided secure biliary access, and wire-guided cholangioscopy enabled successful visualization and fragmentation of the stone. Laser lithotripsy resulted in complete clearance, and the patient’s symptoms resolved rapidly. Liver function tests normalized within days, and no adverse events occurred during recovery.
This case highlights the safety, feasibility, and clinical value of a staged endoscopic strategy combining EUS-guided Hepatico-Gastrostomy with antegrade digital cholangioscopy and laser lithotripsy for the management of large biliary stones in patients with surgically altered anatomy.
This innovative approach may represent a minimally invasive alternative to percutaneous or surgical interventions in selected patients with complex biliary stones and altered anatomy. Future studies are warranted to further evaluate long-term outcomes and define optimal procedural timing and stent strategies.