S15 Percutaneous Antegrade Cholangioscopy: Going Where No Endoscope Has Gone Before

Introduction: The use of Spyglass® cholangioscopy and electrohydraulic lithotripsy (EHL) during endoscopic retrograde cholangiopancreatography (ERCP) has enabled effective management of patients with large, refractory or intrahepatic bile duct stones. ERCP for management of difficult bile duct stones in patients with altered surgical anatomy (necessitating the use of a single balloon enteroscope or pediatric colonoscope), however, remains a challenge. Percutaneous antegrade cholangioscopy (PAC) is an advanced technique that allows the use of cholangioscopy and EHL in patients with altered anatomy. There are few existing case reports in the literature. Our study aimed to describe the safety and efficacy of PAC. Methods: All cases of PAC conducted at Vancouver General Hospital were included. All procedures were performed between June 2022 and June 2023. A retrospective chart review was conducted to collect demographic, procedural and clinical data. Results: 8 patients were included with 10 PAC procedures performed for difficult biliary stone disease. Patient age ranged from 4 to 87 years. 4 patients (50%) had Roux-en-Y hepaticojejunostomy anatomy, 1 (12%) Billroth II, 1 (12%) Roux-en-Y distal gastrectomy, 1 (12%) duodenal switch anatomy, precluding the use of a standard duodenoscope for ERCP. One patient was 4 years of age which also precluded use of the adult duodenoscope. 4 out of 8 patients had an attempted single balloon enteroscopy-assisted ERCP, none of which were successful at stone extraction. 2 patients had attempted colonoscope-assisted ERCP, one of which resulted in a perforation at the gastrojejunostomy site. All patients had minimum 10F percutaneous transhepatic biliary access for 4 weeks prior to PAC. All patients had technical and clinical success. 75% of patients only required one PAC procedure. All patients were managed with periprocedural antibiotics. Adverse events included post-procedural intrahepatic abscesses and occurred in 1 case. This was managed conservatively with a prolonged course of antibiotics (Table 1). Conclusion: PAC is a safe and efficacious procedure for management of difficult biliary stone disease in patients with altered surgical anatomy. Although it necessitates patients to have a percutaneous biliary drain in situ for 4 weeks, the alternative option of multiple unsuccessful attempts at ERCP followed by surgical management is suboptimal. Evaluating appropriate clinical cases in which to proceed with early PAC, may be a more effective method of managing these patients. Table 1. - Patients and procedures Case Age/Gender Anatomy Pathology Prior attempt at ERCP IR drain size Pre/post procedural Abx Number of PAC sessions Adverse events 1 23/M Roux-en-Y hepaticojejunostomy Large intrahepatic biliary stones No 10F Yes/yes 1 None 2 69/M OLTx with Roux-en-Y hepaticojejunostomy Large intrahepatic biliary stones Yes 14F Yes/yes 1 None 3 72/F Duodenal switch Large CBD stones Yes 12F Yes/yes 1 None 4 4/F Native Large CBD stones No 12F Yes/yes 1 None 5 87/M Roux-en-Y distal gastrectomy Large CBD stones Yes 14F Yes/yes 1 None 6 86/M Billroth II Large CBD stones Yes 10F Yes/yes 1 None 7 66/M OLTx Roux-en-Y hepaticojejunostomy Large intrahepatic biliary stones Yes 12F Yes/yes 2 None 8 38/F Roux-en-Y hepaticojejunostomy Large intrahepatic biliary stones Yes 10F Yes/yes 2 Post-procedural hepatic abscesses

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