Passing a camel through the needle’s eye: expanding SpyGlass-assisted biliary interventions

1. Describe and visualize the indications and technicalities of percutaneous endoscopy-assisted biliary interventions in patients with cholelithiasis, biliary strictures, and prior hepaticojejunostomy. 2. Present cases utilizing SpyGlass Direct in the management of cholecystolithiasis versus choledocholithiasis.

Background: Biliary endoscopy is an effective adjunctive tool in managing a variety of biliary pathologies. This is especially true in cases where endoscopic retrograde cholangiopancreatography (ERCP) fails or is unfeasible due to anatomy altered by previous surgery such as hepaticojejunostomy, biliary strictures as seen in primary sclerosing cholangitis, or by extrinsic compression as seen in Mirizzi’s Syndrome and tumor mass effect {1}. In these circumstances, the use of SpyGlass Direct (SD) for pathologies of the biliary tree such as choledocholithiasis is well-recorded; we thus include a case of SD utilization in cholecystolithiasis.

Clinical Findings/Procedure Details: The SD is advanced through a ≥11-Fr sheath, providing a 3.6-Fr working channel to accommodate objective-dependent wires, catheters, and devices. In general, gallstone management with SD is done 4 weeks after percutaneous biliary drainage to minimize bleeding. The biliary drainage catheter is exchanged over a guide wire for a 25-cm vascular sheath using a 12-Fr peel-away sheath to avoid excessive biliary pressurization. A flexible endoscope is used for choledochoscopy, while a rigid endoscope in cholecystoscopy permits a more direct route through the fundus {2}. Once localized, the stone is fragmented and removed. In cases with prior hepaticojejunostomy, endoscopic suture removal rids the anastomosis of potential nidi for new stone formation and, as with strictures, stenting may be used to ensure patency {3}. The procedure concludes with placement of external drain catheter if transhepatic, or transcystic internal–external drainage catheter or a cholecystostomy drain in cholecystoscopy.

Conclusion and/or Teaching Points: While percutaneous endoscopy-assisted biliary interventions for a variety of biliary pathologies gain traction, special considerations and techniques can be considered to optimize outcomes of variant pathologies and patient histories. We highlight cases of SD-utilization in cholecystolithiasis versus choledocholithiasis.