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

Li Z.; Shen X.; Yang Y.; Luo Q.; Tan L.; Wu F. · Journal of visualized experiments : JoVE · 2026

**Background & Methods** This case report describes a novel stepwise therapeutic strategy for managing common bile duct (CBD) stones in a super-elderly patient (92 years old) with prior Billroth II gastrojejunostomy, a surgical anatomy that precludes conventional ERCP. The approach combines urgent percutaneous transhepatic cholangiography drainage (PTCD) for biliary decompression followed by peroral electronic cholangioscopy with holmium laser lithotripsy under direct visualization. **Key Findings** • Emergency PTCD successfully controlled infection and relieved jaundice in the acute phase, providing rapid hemodynamic stabilization and creating a therapeutic window for definitive treatment in a high-risk super-elderly patient with multiple comorbidities (coronary heart disease, atrial fibrillation). • Peroral electronic cholangioscopy with holmium laser lithotripsy effectively fragmented CBD stones using sequential fragmentation and dusting modes, achieving complete stone clearance as confirmed by post-procedural cholangiography without requiring a mature, enlarged biliary sinus tract. • The patient recovered well without procedural complications following PTCD tube removal, demonstrating the safety and efficacy of this minimally invasive multimodal approach in a high-risk population where traditional open surgery and general anesthesia carry prohibitive risks. **Dosage & Administration** The PTCD tract was dilated to 10 Fr to accommodate passage of the peroral electronic cholangioscope. Holmium laser lithotripsy was performed in sequential fragmentation mode followed by dusting mode for stone destruction. Specific laser parameters, energy settings, or duration are not reported. **Safety & Adverse Effects** No procedural complications were reported in this case. The patient avoided risks associated with traditional open biliary surgery, general anesthesia, prolonged preoperative preparation, and extensive surgical trauma. The approach eliminated hemorrhage risks associated with large mature biliary sinus tract requirements in conventional percutaneous transhepatic choledochoscopic lithotripsy (PTCSL). **Evidence Quality** This is a single case report, representing the lowest level of clinical evidence (Level 5). The study describes a novel technique in one super-elderly patient with multiple comorbidities and complex surgical history, limiting generalizability. No comparative data, control group, or larger patient cohort is presented. While the case illustrates innovative problem-solving for a challenging clinical scenario, broader applicability and reproducibility require multicenter studies with larger patient populations.

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