Abstract
Fish bone migration into the bile duct in patients with surgically altered anatomy is a very rare cause of bile duct stones. Recently, balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) is performed for biliary lesions in patients with surgically altered anatomy. We report on a 73-year-old Japanese man with a history of pancreaticoduodenectomy for intraductal papillary mucinous adenoma. A 20 mm long linear hyperattenuating structure in the left intrahepatic bile duct was noted on routine follow-up computed tomography 14 years postoperatively. The linear structure persisted until follow-up computed tomography performed 15 years postoperatively, and the left intrahepatic bile duct was shown to be dilated. We performed BAERCP for the diagnosis and treatment of the linear structure but could not visualize the linear structure in the left intrahepatic bile duct via enteroscopy and fluoroscopy. We removed the enteroscope, leaving the overtube, and inserted the cholangioscope through the overtube over the guide wire. We observed a brown rod-shaped linear structure in the left intrahepatic bile duct and removed it under direct visualization via overtube-assisted cholangioscopy. We conclude that overtube-assisted cholangioscopy was useful for assessing undiagnosed biliary lesions using conventional BAERCP and removing fish bones in the bile duct of the patient with altered gastrointestinal anatomy.
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Acknowledgements
The authors would like to thank Ms. Ayumu Koseki of the Department of Gastroenterology, Faculty of Medicine, Yamagata University, and Ms. Ryoko Murakami of the Institute for Promotion of Medical Science Research, Faculty of Medicine, Yamagata University, for her constructive suggestions about the method used for analyzing the fish bone. The authors would like to thank Enago (www.enago.jp) for the English language review.
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Category 1: conception and design of study: YS, TI, and NM. Acquisition of data: YS, TI, AM, YK, TK, NM, and KA. Analysis and/or interpretation of data: YS, TI, AM, YK, TK, and NM. Category 2: drafting the manuscript: YS and TI. Revising the manuscript critically for important intellectual content: NM. Category 3: approval of the version of the manuscript to be published: YS, TI, AM, YK, TK, NM, KA, FM, and YU.
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12328_2021_1579_MOESM1_ESM.jpg
Supplementary file1 Follow-up magnetic resonance imaging (MRI) 15 years after pancreaticoduodenectomy (PD). Magnetic resonance cholangiopancreatgraphy showed a stenosis of approximately 20 mm at the B2–B3 bifurcation and dilatation of the intrahepatic bile ducts upstream of the stenosis (yellow arrow, stenosis at the B2–B3 bifurcation) (JPG 45 KB)
12328_2021_1579_MOESM2_ESM.jpg
Supplementary file2 Cholangiography using the endoscopic nasobiliary drainage tube 2 days after BAERCP using a cholangioscope. The dilated bile duct showed improvement and no intrahepatic stones (JPG 42 KB)
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Suzuki, Y., Ishizawa, T., Makino, N. et al. A case of successful removal of a migrated fish bone in the bile duct after pancreaticoduodenectomy using overtube-assisted cholangioscopy. Clin J Gastroenterol 15, 493–499 (2022). https://doi.org/10.1007/s12328-021-01579-0
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DOI: https://doi.org/10.1007/s12328-021-01579-0