Endoscopic biliary interventions through the choledochoduodenostomy

Introduction: Biliary cannulation is a well established procedure during ERCP. In case of failed cannulation we usually apply precutting on the papilla of Vater. Occasionally, we can reach the common bile duct from proximally, through a previously performed choledochoduodenostomy. Case: An 83-years-old female was admitted to our unit because of biliary pain and obstruction. The MRCP suggested suspition of common bile duct stones. Cholecystectomy was performed 40 years ago, followed by choledochoduodenostomy two years later in her history. The cannulation of the papilla was impossible because of hidden position of it in the large juxtapapillary diverticula. Therefore, we pushed a guidewire from the choledochoduodenostomy – found in the duodenal bulb-, to the direction of the papilla. The wire entered the duodenum through the papillary orifice. Then we pulled out the endoscope leaving the guidewire in place. After repeated intubation of the duodenum with the scope, we found the papilla to be lifted into the duodenum from the diverticula, making the cannulation quick and easy. After papillotomy a wire was advanced into the intrahepatic bile ducts and the proximally localized stones were removed by extraction balloon. The stones passed either through the papilla or anastomosis. At the end a temporary plastic stent was placed into the proximal bile duct bridging biliodigestive anastomosis. Three months later at elective ERCP the stent and residual small stones were removed. This time we pushed extraction balloon downwards from the biliodigestive anastomosis to clear the distal part of the bile ducts. Conclusion: A variety of endoscopic interventions can be performed through the choledochoduodenostomy.