Cholangioscopic evaluation of distal bile duct stones and intraductal lesions in a patient with anomalous junction of pancreaticobiliary ducts and pancreatic duct anomaly

Cholangioscopic evaluation of distal bile duct stones and intraductal lesions in a patient with anomalous junction of pancreaticobiliary ducts and pancreatic duct anomalyCholangioscopy is now widely performed in patients with pancreaticobiliary disorders, including difficult common bile duct (CBD) stones and indeterminate biliary strictures.Furthermore, an increasing number of rare pancreaticobiliary disorders have been identified by cholangioscopy when fluoroscopy fails to provide a definitive diagnosis [1][2][3][4].A 46-year-old woman was admitted for the treatment of a distal CBD stone, which cannot be identified under percutaneous cholangioscopy through the T-tube after laparoscopy cholecystectomy and CBD exploration.Fluoroscopy suggested an irregular stone in the distal CBD and choledochal cyst.Due to the unavailability of laser or electrohydraulic lithotripsy devices, the stone could not be captured with the retrieval basket under cholangioscopic guidance.Finally, following unsuccessful attempts with foreign body forceps, the CBD stone was successfully extracted using a standard retrieval basket under fluoroscopic guidance ( Fig. 1 a-c).While CBD stone clearance was confirmed on cholangioscopy, an intraductal E-Videos Video 1 Cholangioscopy-guided biopsy. Fig. 1 Fluoroscopy and duodenoscopy.a Fluoroscopy revealed an irregular stone in the distal CBD and choledochal cyst, and an unsuccessful stone extraction attempt using foreign body forceps (red arrow: distal CBD stone and yellow arrow: choledochal cyst).b The CBD stone was successfully extracted using a standard retrieval basket under fluoroscopic guidance (red arrow).c A duodenoscope revealed the CBD stone. Fig. 2 Cholangioscopy and fluoroscopy.a A CBD stone was identified under the cholan- gioscopy.b A protruding lesion with an intensely hyperemic and irregular surface was observed near the biliary orifice (red arrow: intraductal neoplasm and yellow arrow: common bile duct orifice).c, d Multiple openings were noted under cholangioscopy, and fluoroscopicguided guidewire cannulation demonstrated that these represented pancreatic duct orifices (red arrow: pancreatic duct orifices and yellow arrow: pancreatic duct).