Percutaneous Cholangioscopic Lithotripsy for Afferent Loop Syndrome Caused by Enterolith Development after Roux-en-Y Hepaticojejunostomy: A Case Report
A 74-year-old woman was admitted with a 2-day history of fever and acute abdominal pain. The patient had undergone choledochal cyst excision, left hepatectomy, and RYHJ for IHD stones and a choledochal cyst 12 years previously. On admission, blood pressure was 90/57 mm Hg, pulse rate was 116 beats per minute, temperature was 38.5℃, and tenderness in the right upper quadrant of the abdomen was detected. Laboratory findings were as follows: white blood cell count, 14,900/mm3 (normal range, 4,000 to 10,800); platelet cell count, 81,000/mm3 (normal range, 150,000 to 400,000); C-reactive protein, 11 mg/dL (normal range, 0 to 0.3); aspartate aminotransferase, 129 IU/L (normal range, 7 to 38); alanine aminotransferase, 187 IU/L (normal range, 4 to 43); total bilirubin, 6.2 mg/dL (normal range, 0.1 to 1.3); and alkaline phosphatase, 432 IU/L (normal range, 103 to 335). An abdominal computed tomography (CT) scan showed a single stone in the sixth branch of the right IHD and a stone measuring 3 cm in the afferent loop with diffuse dilatation of the upstream small bowel loop and IHD (). Afferent loop syndrome caused by an enterolith was diagnosed on the basis of the clinical features and imaging studies.\nBecause the patient was septic and her condition was unstable, we performed urgent percutaneous transhepatic biliary drainage (PTBD). A 10 Fr pigtail catheter for PTBD was passed over the guide wire and placed in the jejunal limb through B6 after B6 of the IHD was punctured using a 21-gauge hollow needle under ultrasound guidance, and a guide wire was inserted through the needle into the bile duct. After PTBD, the patient showed a gradual improvement of her general condition. Because the enterolith was located in the jejunal limb near the hepaticojejunostomy site on abdominal CT and cholangioenterogram, peroral endoscopic access to the enterolith was difficult, and surgical treatment was refused by the patient, we decided to perform percutaneous transhepatic cholangioscopy (PTCS) for removal of the IHD stone and the enterolith. First, the PTBD tract was dilated to 18 Fr using a dilator to allow insertion of a standard choledochoscope (CHFP20Q; Olympus Co., Tokyo, Japan) into the bile duct 7 days after PTBD. One week later, PTCS was performed for stone removal. Cholangioscopic examination showed an IHD stone and a large enterolith. The IHD stone was a black-pigmented stone and the jejunal loop stone was grayish and hard (). Because the hepaticojejunostomy site was not stenotic and an enterolith was located in the jejunal limb near the hepaticojejunostomy site, the cholangioscope could access the enterolith. Electrohydraulic lithotripsy (EHL) was performed to fragment the enterolith. An electrohydraulic shock wave generator (Lithotron EL 25; Walz-electronic Inc., Rohrdorf, Germany) set at an output of 2,000 V was used for the generation of shock waves of increasing frequency (intensity of 500 mJ), which were applied with a continuous sequence of discharge. After stone fragmentation, the enterolith was pushed out through the jejunojejunal anastomosis to the efferent loop using the cholangioscope and a saline flush (). The cholangiogram showed that the IHD and the afferent loop were clear, without any remnant stone. The PTBD catheter was removed, and the patient began oral intake 1 day after the procedure. The patient made a full recovery without any complications, and was discharged 2 days after the procedure.