Utility of cholangioscopy in patients with surgically altered anatomy after percutaneous transhepatic biliary drainage

Abstract

Background and study aims

Surgical therapy that alters the biliary anatomy makes endoscopic access to the biliary system difficult. These surgeries promote cholestasis, calculi development and lead to biliary stricture. Stricture resolution and removal of intrahepatic bile duct stones remain challenging.

Patients and methods

This was a retrospective analysis of prospective data from patients with altered surgical anatomy with intrahepatic bile duct stones/strictures. Percutaneous transhepatic biliary drainage (PTBD) was attempted, followed by transhepatic SpyGlass cholangioscopy for stricture or removal of intrahepatic bile duct stones. The number of sessions, stricture dilatation, and complications were noted. A cholangiogram revealing a clear duct was a technical success, and stricture resolution was considered a clinical success. Complete ductal clearance was clinical success in those with stones. Patients with follow-up of a minimum of 6 months were included.

Results

Twenty-four patients, 16 of whom were male (66.7%), median age 41.5 years (interquartile range [IQR] 38.2–49) successfully underwent PTBD. The most common indication was biliary stricture in 13 (54.2%), followed by intrahepatic stones in six (25%) and stones with strictures in five patients (20.8%). Most patients had undergone Roux-en-Y hepaticojejunostomy (22; 91.7%), and the level of bile duct obstruction was hilum in 20 (83.3%). The median (IQR) total bilirubin levels reduced from 6.6 (5.1–8.3) to 1.8 mg/dL (1.2–2.8) after PTBD; P <0.001. The technical success was 90.9% after a median (IQR) number of two (1.7–2) SpyGlass sessions; clinical success was 88.9% after a median of three (3–4) SpyGlass sessions. Abdominal pain (8.3%) and cholangitis (12.5%) were the complications after cholangioscopy. The median (IQR) follow-up duration was 7 months (6–8).

Conclusions

SpyGlass cholangioscopy, although challenging, is a safe option for intrahepatic stones and strictures with excellent short-term outcomes and minimal complications.

Keywords

Pancreatobiliary (ERCP/PTCD) - Cholangioscopy - PTCD/PTCS

• References

• 1 Buxbaum JL, Abbas Fehmi SM. ASGE Standards of Practice Committee. et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89: 1075-1105
• 2 Cha SW. Management of intrahepatic duct stone. Korean J Gastroenterol 2018; 71: 247-252
• 3 Ran X, Yin B, Ma B. Four major factors contributing to intrahepatic stones. Gastroenterol Res Pract 2017; 2017: 7213043
• 4 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491
• 5 Jegadeesan M, Goyal N, Rastogi H. et al. Percutaneous transhepatic biliary drainage for biliary stricture after endotherapy failure in living donor liver transplantation: A single-centre experience from India. J Clin Exp Hepatol 2019; 9: 684-689
• 6 Rela M, Rammohan A. The current status of endotherapy in the management of biliary strictures after right lobe living donor liver transplantation. Transplantation 2022; 106: 241-242
• 7 Nakayama F, Soloway RD, Nakama T. et al. Hepatolithiasis in East Asia. Retrospective study. Dig Dis Sci 1986; 31: 21-26
• 8 Pausawasdi A, Watanapa P. Hepatolithiasis: epidemiology and classification. Hepatogastroenterology 1997; 44: 314-316
• 9 Lorio E, Patel P, Rosenkranz L. et al. Management of hepatolithiasis: Review of the literature. Curr Gastroenterol Rep 2020; 22: 30
• 10 Chon HK, Choi KH, Seo SH. et al. Efficacy and safety of percutaneous transhepatic cholangioscopy with the Spyglass DS Direct Visualization System in patients with surgically altered anatomy: A pilot study. Gut Liver 2022; 16: 111-117
• 11 Tripathi N, Mardini H, Koirala N. et al. Assessing the utility, findings, and outcomes of percutaneous transhepatic cholangioscopy with Spyglass Direct visualization system: a case series. Transl Gastroenterol Hepatol 2020; 5: 12
• 12 Dalal A, Patil G, Kamat N. et al. Utility of the novel SpyGlass DS II system and laser lithotripsy for choledocholithiasis in pregnancy. GE Port J Gastroenterol 2021; 29: 172-177
• 13 Jamwal K, Sharma MK, Sharma BC. et al. Endoscopic drainage of obstructed biliary system in altered gastrointestinal anatomy: An experience from a tertiary center in India. Indian J Gastroenterol 2018; 37: 299-306
• 14 Park HS, Lee JM, Kim SH. et al. Differentiation of cholangiocarcinoma from periductal fibrosis in patients with hepatolithiasis. Am J Roentgenol 2006; 187: 445-453
• 15 Ozcan N, Kahriman G, Mavili E. Percutaneous transhepatic removal of bile duct stones: results of 261 patients. Cardiovasc Intervent Radiol 2012; 35: 890-897
• 16 Veld JV, van Huijgevoort NCM, Boermeester MA. et al. A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave. Endoscopy 2018; 50: 896-909
• 17 Maier M, Kohler B, Benz C. et al. Percutaneous transhepatic cholangioscopy (PTCS)--an important supplement in diagnosis and therapy of biliary tract diseases (indications, technique and results). Z Gastroenterol 1995; 33: 435-439
• 18 Chen MF, Jan YY. Bacteremia following postoperative choledochofiberoscopy-a prospective study. Hepatogastroenterology 1996; 43: 586-589
• 19 Kint JF, van den Bergh JE, van Gelder RE. et al. Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients. Dig Surg 2015; 32: 9-15
• 20 Yeh YH, Huang MH, Yang JC. et al. Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up. Gastrointest Endosc 1995; 42: 13-18
• 21 Ponchon T, Genin G, Mitchell R. et al. Methods, indications, and results of percutaneous choledochoscopy. A series of 161 procedures. Ann Surg 1996; 223: 26-36
• 22 Hayashi N, Sakai T, Yamamoto T. et al. Percutaneous transhepatic lithotripsy using a choledochoscope: long-term follow-up in 14 patients. Am J Roentgenol 1998; 171: 1387-1389
• 23 Courtois CS, Picus DD, Hicks ME. et al. Percutaneous gallstone removal: long-term follow-up. J Vasc Interv Radiol 1996; 7: 229-234
• 24 Lee SK, Seo DW, Myung SJ. et al. Percutaneous transhepatic cholangioscopic treatment for hepatolithiasis: an evaluation of long-term results and risk factors for recurrence. Gastrointest Endosc 2001; 53: 318-323
• 25 Tazuma S. Gallstone disease: Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20: 1075-1083
• 26 Fan ST, Choi TK, Lo CM. et al. Treatment of hepatolithiasis: improvement of result by a systematic approach. Surgery 1991; 109: 474-480
• 27 Alabraba E, Travis S, Beckingham I. Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports. World J Gastrointest Endosc 2019; 11: 298-307
• 28 Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013; 25: 376-385
• 29 Hakuta R, Sato T, Nakai Y. et al. Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography for hepatolithiasis in patients with hepaticojejunostomy. Surg Endosc 2024; 38: 2423-2432
• 30 Mori T, Sugiyama M, Atomi Y. Gallstone disease: Management of intrahepatic stones. Best Pract Res Clin Gastroenterol 2006; 20: 1117-1137
• 31 Kalaitzakis E, Webster GJ, Oppong KW. et al. Diagnostic and therapeutic utility of single-operator peroral cholangioscopy for indeterminate biliary lesions and bile duct stones. Eur J Gastroenterol Hepatol 2012; 24: 656-664