Keywords
percutaneous lithotripsy - biliary stones - holmium laser
Introduction
Currently, the treatment of choice in bile duct stones is endoscopic retrograde cholangiopancreatography
(ERCP), followed by laparoscopic cholecystectomy.[1] However, factors such as variant anatomy of the ampulla of Vater, presence of duodenal
diverticula, surgical procedures such as roux en Y gastric bypass, and hepaticojejunostomy
can limit the success of ERCP. Options in such cases are limited and include peritoneoscopic
biliary surgery, transhepatic stone removal using dormia basket, or predilating the
papilla with balloons and clearing the stones.[2] Laser lithotripsy, by either per-oral endoscopy or a percutaneous transhepatic approach,
is a very good alternative for such difficult/complicated biliary stones. We report
our technique and experience in a series of three patients who underwent percutaneous
transhepatic biliary drainage (PTBD), followed by percutaneous transhepatic laser
lithotripsy in an attempt to avoid open surgery when ERCP was technically difficult.
Case 1
A 49-year-old female, who underwent Whipple surgery for pancreatic carcinoma 5 years
ago, presented with fever, vomiting, and pruritus. Laboratory values showed signs
of cholestasis and inflammation ([Table 1]). Magnetic resonance cholangiopancreatography (MRCP) showed common hepatic duct
(CHD) stone of size 13 × 24 × 42 mm close to hepaticojejunostomy (HJ) site with mild
biliary dilatation and possible stricture at the anastomosis (
[Fig. 1A]
). Hence, the final diagnosis was choledocholithiasis and cholangitis. As ERCP was
difficult due to post HJ status, PTBD followed by interval percutaneous transhepatic
laser lithotripsy was planned.
Table 1
Table showing improvement in LFT values postprocedure
|
Cases
|
Criteria
|
Preoperative
|
Postoperative
|
|
Abbreviations: ALP, alkaline phosphatase; D. bilirubin, direct bilirubin; GGT, gamma
glutamyl transferase; LFT, liver function test; TC, total count.
|
|
Case 1
|
ALP
|
762 U/L
|
215 U/L
|
|
GGT
|
666 U/L
|
78 U/L
|
|
D. bilirubin
|
1.89 mg/dl
|
0.13 mg/dl
|
|
TC
|
13500
|
9000
|
|
Neutrophils
|
84%
|
40–80%
|
|
Case 2
|
ALP
|
165 U/L
|
121 U/L
|
|
GGT
|
180 U/L
|
51 U/L
|
|
D. bilirubin
|
2.28 mg/dl
|
0.19 mg/dl
|
|
TC
|
13000
|
8500
|
|
Neutrophils
|
90%
|
40–80%
|
|
Case 3
|
ALP
|
977 U/L
|
290 U/L
|
|
GGT
|
1232 U/L
|
141 U/L
|
|
D. bilirubin
|
0.23 mg/dl
|
0.14 mg/dl
|
|
TC
|
16000
|
9000
|
|
Neutrophils
|
90%
|
40–80%
|
Fig. 1 (A) Case 1–Magnetic resonance cholangiopancreatography (MRCP) showing large stone in
the common hepatic duct with mild biliary dilatation and possible stricture at the
hepaticojejunostomy (HJ) anastomosis and pancreatic ductal calculi can also be seen.
(B) Case 1–Percutaneous transhepatic cholangiogram showing a large filling defect near
the HJ site suggestive of calculus. (C) Case 1–Fluoroscopy image showing an 8.5 F internal-external percutaneous transhepatic
biliary drainage (PTBD) catheter across the calculus.
-
Percutaneous transhepatic biliary drainage: Broad- spectrum antibiotic (inj. Cefoperazone 1000 mg + 500 mg sulbactam) was given
1 hour before the procedure and 8 hours after the procedure. The procedure was done
under local anesthesia and IV sedation. Under ultrasound and fluoroscopic guidance,
the left hepatic duct branch was punctured, and access was secured by 5 F sheath (Accustick;
Boston Scientific), followed by 7 F sheath (Translumina 7F femoral introducer sheath).
A 5 F catheter (40 cm Kumpe catheter) was navigated into the left hepatic duct, and
cholangiogram showed intrahepatic biliary radical dilatation (IHBRD) and a large filling
defect in the CHD close to HJ site suggestive of calculus. A hydrophilic guidewire
(260 cm 035” angled tip; Terumo) was negotiated across the CHD stone into the jejunum
([Fig. 1]B), which was exchanged for a stiff guidewire (260 cm 035” J tip PTFE coated; Translumina).
An 8.5 F internal-external drainage catheter was placed across the stone into the
jejunum ([Fig. 1]C). The postoperative period was uneventful and she was discharged with PTBD catheter
closed externally. Three weeks later, she got admitted for percutaneous laser lithotripsy.
-
Percutaneous transhepatic laser lithotripsy: Procedure was done under general anesthesia (GA) with antibiotic prophylaxis. Under
fluoroscopic guidance, contrast was injected into the PTBD catheter, which showed
the contrast in the jejunum. The PTBD catheter was removed over a stiff guidewire
(035” 260 cm J tip PTFE coated; Translumina). The PTBD tract was dilated with tissue
dilators, and a 12 F access sheath (flexor ureteral access sheath with AQ hydrophilic
coating; 12F/ 35 cm; Cook Medical) was inserted ([Fig. 2]A). Through the 12 Fr sheath, a flexible choledochoscope (KARL STORZ 11292 ADU1)
was introduced for direct visualization of stones ([Fig. 2]B). Laser lithotripsy of the stone was done using holmium laser fiber (Lumenis slimline
SIS 365micron). Continuous warm saline irrigation was done during lithotripsy. After
lithotripsy, choledochoscope was removed over the guidewire, and balloon plasty of
the CHD and hepaticojejunostomy site was done using a 10 × 40 mm balloon catheter
([Fig. 2]C). The final cholangiogram obtained through a 10 F vascular sheath showed adequate
drainage of bile without filling defects ([Fig. 2]D). A 14 F internal-external drainage catheter was placed across the HJ into the
jejunum ([Fig. 2]E). The patient tolerated the procedure well, and she was discharged in a stable
condition with the PTBD catheter closed externally (
[Table 1]
). Follow-up cholangiogram after 3 months showed free flow of contrast into the jejunum
with no filling defects/IHBRD ([Fig. 2]F). Hence, the PTBD catheter was removed.
Fig. 2 (A) Case 1–Fluoroscopy image showing 12 F sheath for cholangioscopy which was exchanged
with percutaneous transhepatic biliary drainage (PTBD) catheter over an 035 guidewire
after tract dilatation. (B) Case 1–Cholangioscopy image showing stone within the common hepatic duct (CHD).
(C) Case 1–Fluoroscopy image showing balloon dilatation of the hepaticojejunostomy (HJ)
site done with a 10 × 40 mm balloon catheter after LASER lithotripsy. (D) Case 1–Cholangiogram showing the free flow of bile after LASER lithotripsy and balloon
plasty of the HJ site. (E) Case 1–Fluoroscopy image showing 14 F internal-external drainage catheter placed
across the HJ after lithotripsy and balloon plasty of HJ site. (F) Case 1–Follow-up cholangiogram demonstrated adequate drainage of bile without any
filling defects.
Case 2
A 72-year-old male presented with abdominal pain, fever, and vomiting. His laboratory
values showed signs of cholestasis and inflammation ([Table 1]). USG abdomen showed features of acute calculous cholecystitis. MRCP showed choledocholithiasis
and calculus cholecystitis. The final diagnosis was acute calculous cholecystitis,
choledocholithiasis, and cholangitis. ERCP was difficult as there was a history of
roux-en–Y gastrojejunostomy for duodenal ulcer. Hence, after all preoperative evaluation,
he underwent laparotomy, adhesiolysis, subtotal cholecystostomy, exploration of common
bile duct (CBD), choledocholithotomy, intraoperative cholangiogram, and T- tube placement,
under GA. The postoperative period was uneventful and he was discharged in a stable
condition. One month later, he started complaining of right upper quadrant pain. T-tube
cholangiogram showed IHBRD and two filling defects of size 9 × 13 mm and 10 × 14 mm
suggestive of CBD calculi (
[Fig. 3A]
). As ERCP was difficult, he underwent PTBD (
[Fig. 3B], [C]
), followed by interval laser lithotripsy for the clearance of CBD calculi. The patient
was discharged in a stable condition with the PTBD catheter closed externally ([Table 1]). Follow-up cholangiogram after 2 weeks showed adequate drainage of bile with no
filling defects. Hence, the PTBD catheter was removed.
Fig. 3 (A) Case 2–T tube cholangiogram showing filling defects in the common bile duct (CBD)
suggestive of calculus. (B) Case 2–Percutaneous transhepatic cholangiogram showing filling defects in the CBD
suggestive of stone. (C) Case 2–Fluoroscopy image showing an 8.5 F percutaneous transhepatic biliary drainage
(PTBD) catheter placed across the CBD stone into the duodenum.
Case 3
A 75-year-old male, who underwent hepaticojejunostomy for choledochal cyst 10 years
ago, presented with fever for 1 month. His laboratory values showed signs of cholestasis
and inflammation ([Table 1]). Ultrasound abdomen showed IHBRD with a calculus of size 20 x17 × 28 mm in the
CHD near the HJ site. The final clinical diagnosis was posthepaticojejunostomy, obstructive
jaundice due to CHD stone and cholangitis. As ERCP was difficult due to post HJ status,
he underwent PTBD ([Fig. 4A-C]), followed by interval percutaneous transhepatic laser lithotripsy. Postlithotripsy,
the patient developed fever and chills, and antibiotics were hiked as per blood culture
report. He was discharged in a hemodynamically stable condition with the PTBD catheter
closed externally ([Table 1]). Follow-up cholangiogram at 3 months showed free flow of contrast into the jejunum
with no filling defects/IHBRD (
[Fig. 4D], [E]
). Hence, the PTBD catheter was removed.
Fig. 4 (A) Case 3–Cholangiogram showing a large filling defect in the common hepatic duct (CHD)
near the hepaticojejunostomy (HJ) site suggestive of calculus. (B) Case 3–Fluoroscopy image showing guidewire across the HJ stone into the jejunum.
(C) Case 3–Fluoroscopy image showing a 7 F catheter placed across the HJ stone into
the jejunum. (D) Case 3–Fluoroscopy image showing 14 F percutaneous transhepatic biliary drainage
(PTBD) catheter (placed after lithotripsy) in situ. (E) Case 3–Follow-up cholangiogram showing the free flow of contrast into jejunum without
any filling defects in the CHD.
Discussion
Bile duct stones occur as a result of either formation of stones within intrahepatic/extrahepatic
bile ducts or the passage of gall stones into the CBD. CBD stones are estimated to
be present in 10 to 20% of individuals with symptomatic gallstones.[3] Bile duct stones are considered a troublesome postoperative adverse event in patients
with a hepatobiliary pancreatic disease undergoing hepaticojejunostomy. These are
mostly caused by cholestasis or reflux cholangitis. Both complete stone clearance
and maintained resolution of any HJ/intrahepatic stricture using minimally invasive
treatment is ideal and essential for these patients.[4]
Currently, most of the biliary calculi are successfully removed either at the time
of laparoscopic cholecystectomy or pre- or postoperatively with ERCP. Increasing populations
of patients are unable to have their stones removed endoscopically because the stones
are too large or impacted or previous surgical procedures make the papilla inaccessible.
Open CBD exploration is reserved for such patients who are not candidates for endoscopic
or laparoscopic procedures. However, it may be associated with other morbidities.
Percutaneous stone removal is a minimally invasive technique for the management of
such difficult cases.[5]
Percutaneous approach to biliary stone removal was first undertaken in 1962 when Dr.
Mondet extracted a retained CBD stone through a T tube using forceps. Percutaneous
access can be achieved by a variety of methods, namely, transhepatic, T-tube, cholecystostomy
tube and, rarely, transcystic route. Transhepatic access is the most common route
used nowadays. Various percutaneous techniques of biliary stone removal have been
described in the literature, including stone extraction by forceps or baskets; antegrade
expulsion of stones into the duodenum by forceful irrigation, or with the aid of various
angioplasty balloon catheters, with or without stone fragmentation (lithotripsy);
chemolitholysis; sphincteroplasty and stricture dilatation.[6] Adapted from endoscopic management of urinary calculi, cholangioscopy has since
emerged as an alternative method of stone clearance for complex cases of choledocholithiasis.
Lithotripsy is a therapeutic adjunct that improves success rate in patients undergoing
video cholangioscopy-guided clearance of biliary calculi, especially for the clearance
of large, impacted, and irregularly shaped calculi. Lithotripsy may be performed by
intracorporeal approaches using mechanical, electrohydraulic, or laser devices at
the time of ERCP or percutaneous access, or by extracorporeal shock wave lithotripsy.
Lee et al retrospectively reviewed 34 consecutive patients who underwent unsuccessful
removal of CBD stones using conventional endoscopic methods and were subsequently
treated using percutaneous cholangioscopy-guided stone clearance (combining conventional
methods and electrohydraulic lithotripsy). Complete stone clearance was achieved in
all cases with only 6% major complication rate (hemobilia, PTBD tract disruption).[7]
The holmium laser is a small contact lithotrite (200 µm to 1000 µm) that effectively
fragments urinary stones with minimal stone retropulsion and subsequent collateral
damage to surrounding tissue. Percutaneous transhepatic cholangioscopic laser lithotripsy
with holmium:yttrium-aluminum-garnet (holmium: YAG) laser has been shown to effectively
clear stones without serious procedure-related complications.[8]
Several small series, with a mean of 16 patients (range 9–22 patients) have validated
the usefulness of holmium laser lithotripsy for the treatment of difficult biliary
calculi. Shamamian and Grasso reported a much larger series of 36 patients with complex
intrahepatic biliary calculi (22 primary and 14 secondary intrahepatic calculi); of
these, 22 were treated with percutaneous endoscopic holmium laser lithotripsy. Complete
stone clearance was accomplished in all patients without major complications. No recurrence
or major complications were identified during the follow-up period ranging from 6
to 25 months.[9]
Recently, percutaneous transhepatic cholangioscopy (PTCS) with Spyglass Direct visualization
system has been described, which allows access to the biliary tree with direct visualization
and sampling of the bile duct via cholangioscopy, and additionally facilitates optically
guided intraductal fragmentation and clearance of biliary calculi.[10]
Tsutsumi et al have compared treatment methods for bile duct stones after hepaticojejunostomy
between percutaneous transhepatic cholangioscopy (PTCS) and peroral, short double-balloon
enteroscopy (sDBE). Forty consecutive patients were treated for bile duct stones after
hepaticojejunostomy. The initial success rates for biliary access were 100% with PTCS
and 91% with sDBE. The rate of true complete stone clearance was similar to PTCS and
sDBE. He concluded that, compared with PTCS, peroral endoscopic procedures using an
sDBE for managing bile duct stones in patients with prior hepaticojejunostomy was
useful and had low rates of adverse events and a short hospitalization.[4]
Our series of patients had large/complex biliary calculi that were effectively managed
through the coordinated efforts of the interventional radiology and urology teams.
All three patients were visually stone-free after one cholangioscopic lithotripsy
procedure. No major perioperative/postoperative complications occurred. The mean length
of hospital stay was 2 days. At 3 months radiologic follow-up, no retained stones/stone
recurrence was noted. Although previous reports of this technique exist, this case
series contributes to the growing body of literature supporting the use of multidisciplinary
techniques, including interventional radiology in treating retained and sometimes
large biliary calculi.
In conclusion, percutaneous transhepatic laser lithotripsy in our experience represents
a minimally invasive approach, safe, accompanied by a high-success rate, minimal morbidity,
and a short hospital stay. It can be considered for those cases in which an endoscopic
approach has failed or is technically difficult. Success depends on a multidisciplinary
approach.
