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      Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones

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          Abstract

          Background/Aims

          Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones.

          Methods

          This study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL.

          Results

          Among 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality.

          Conclusions

          Despite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

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          Most cited references25

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          Complications of endoscopic biliary sphincterotomy.

          M L Freeman, D Nelson, S. Sherman … (1996)
          Endoscopic sphincterotomy is commonly used to remove bile-duct stones and to treat other problems. We prospectively investigated risk factors for complications of this procedure and their outcomes. We studied complications that occurred within 30 days of endoscopic biliary sphincterotomy in consecutive patients treated at 17 institutions in the United States and Canada from 1992 through 1994. Of 2347 patients, 229 (9.8 percent) had a complication, including pancreatitis in 127 (5.4 percent) and hemorrhage in 48 (2.0 Percent). There were 55 deaths from all causes within 30 days; death was directly or indirectly related to the procedure in 10 cases. Of five significant risk factors for complications identified in a multivariate analysis, two were characteristics of the patients (suspected dysfunction of the sphincter of Oddi as an indication for the procedure and the presence of cirrhosis) and three were related to the endoscopic technique (difficulty in cannulating the bile duct achievement of access to the bile duct by "precut" sphincterotomy, and use of a combined percutaneous-endoscopic procedure). The overall risk of complications was not related to the patient's age, the number of coexisting illnesses, or the diameter of the bile duct. The rate of complications was highest when the indication for the procedure was suspected dysfunction of the sphincter of Oddi (21.7 percent) and lowest when the indication was removal of bile-duct stones within 30 days of laparoscopic cholecystectomy (4.9 percent). As compared with those who performed fewer procedures, endoscopists who performed more than one sphincterotomy per week had lower rates of all complications (8.4 percent vs. 11.1 percent, P=0.03) and severe complications (0.9 percent vs. 2.3 percent, P=0.01). The rate of complications after endoscopic biliary sphincterotomy can vary widely in different circumstances and is primarily related to the indication for the procedure and to endoscopic technique, rather than to the age or general medical condition of the patients.
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            SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video).

            Douglas Pleskow, K. Chen (2007)
            Clinical implementation of cholangioscopy for direct visual examination of bile ducts, tissue sampling, and therapeutic maneuvers has been slowed by limitations in available technology. With 4-way deflected steering and dedicated irrigation channels, the single-operator SpyGlass peroral cholangiopancreatoscopy system is designed to overcome some of these limitations. To evaluate the clinical utility and safety of the SpyGlass system for diagnostic and therapeutic endoscopic procedures in bile ducts. Prospective observational clinical feasibility study. Two tertiary referral centers. Procedural success rate defined as the proportion of SpyGlass procedures in which the diagnostic or therapeutic objectives of the procedure were achieved. SpyGlass procedures were performed in 35 patients: 22 with indeterminate strictures (63%), 5 with indeterminate filling defects (14%), 5 with stones (14%), 2 with cystic lesions (6%), and 1 patient with an indication for gallbladder stent placement (3%). The rate of procedural success was 91% (95% confidence interval 77%-98%). Twenty patients underwent SpyGlass-directed biopsy, and the specimens procured from 19 patients (95%) were found adequate for histologic evaluation. The preliminary sensitivity and specificity of SpyGlass-directed biopsy to diagnose malignancy were 71% and 100%, respectively. SpyGlass-directed electrohydraulic lithotripsy succeeded in 5 of 5 patients (100%). Procedure-related complications occurred in 2 patients (6%) and resolved uneventfully. No control group was included. Follow-up for determining preliminary sensitivity and specificity was limited. SpyGlass procedures proved to be clinically feasible, provided adequate samples for histologic diagnosis, and successfully guided stone therapy. The procedures were safe and well tolerated. Prospective multicenter clinical trials of the system are underway.
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              Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis.

              Yan Chen, Deok-Hwan Yang, Min Huang … (2003)
              Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL. This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1-22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence. PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026). PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Endosc
                Journal ID (iso-abbrev): Clin Endosc
                Journal ID (publisher-id): CE
                Title: Clinical Endoscopy
                Publisher: The Korean Society of Gastrointestinal Endoscopy
                ISSN (Print): 2234-2400
                ISSN (Electronic): 2234-2443
                Publication date (Print): January 2013
                Publication date (Electronic): 31 January 2013
                Volume: 46
                Issue: 1
                Pages: 65-70
                Affiliations
                [1 ]Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
                [2 ]Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
                Author notes
                Correspondence: Hyung Wook Kim. Department of Internal Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, 20 Geumo-ro, Yangsan 626-787, Korea. Tel: +82-55-360-1535, Fax: +82-55-360-1536, mdkhwook@ 123456gmail.com
                Article
                DOI: 10.5946/ce.2013.46.1.65
                PMC ID: 3572354
                PubMed ID: 23423471
                SO-VID: 8990693e-8727-48d9-a126-7be624b10472
                Copyright © Copyright © 2013 Korean Society of Gastrointestinal Endoscopy
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 05 January 2012
                Date revision received : 16 April 2012
                Date accepted : 20 April 2012
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: percutaneous transhepatic cholangioscopic lithotomy,common bile duct stones
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: percutaneous transhepatic cholangioscopic lithotomy, common bile duct stones

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