PTCD and Peroral Electronic Cholangioscopy with Holmium Laser Lithotripsy for CBD Stones in a Super-Elderly Patient Post-Billroth II Gastrojejunostomy.

The management of impacted common bile duct stones in patients with prior Billroth II gastrectomy poses unique challenges. Altered gastrointestinal anatomy renders duodenoscope passage and biliary cannulation during conventional ERCP exceedingly difficult, resulting in a low success rate. Super‑elderly (over 90 years old) patients often have multiple comorbidities such as cardiovascular diseases and require rapid relief of biliary obstruction and infection control to create a subsequent therapeutic window. Meanwhile, traditional open biliary surgery and general anesthesia carry prohibitive risk, along with prolonged preoperative preparation and extensive trauma. Although percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) is unaffected by gastrointestinal reconstruction, it often depends on a large mature biliary sinus tract, necessitating a multi‑stage procedure, entails a risk of hemorrhage, and has difficulty in managing stones, especially papillary impacted stones. To overcome these difficulties, an innovative stepwise strategy was devised comprising "urgent PTCD for rapid decompression followed by multimodal lithotripsy under direct visualization with a peroral electronic cholangioscope." A 92‑year‑old male had a history of multiple surgeries, including Billroth II gastrectomy, cholecystectomy, and colon resection, along with coronary heart disease and atrial fibrillation. Emergency PTCD was performed first, promptly controlling infection and relieving jaundice. After preoperative preparation, the tract was dilated to 10 Fr, and a peroral electronic cholangioscope was introduced through the sheath. Under direct visualization, the common bile duct stones were efficiently fragmented using a holmium laser, initially in a fragmentation mode and then in a dusting mode. Post‑procedural cholangiography confirmed complete stone clearance. The PTCD tube was subsequently removed uneventfully, and the patient recovered well without complications. This strategy successfully circumvents the anatomical alterations, integrates biliary drainage, direct intra‑ductal visualization, and lithotripsy, providing a minimally invasive treatment strategy for patients with bile duct stones after gastrointestinal reconstruction, especially for super‑elderly and other high‑risk individuals.