Combined radiological-endoscopic management of difficult bile duct stones: 18-year single center experience

Percutaneous transhepatic choledochoscopy in the management of hepatolithiasis: a narrative review

Background and Objective

From the 1980s and continuing into the 21st century, percutaneous transhepatic choledoscopy (PTCS) has been increasingly used in the clinical management of cholelithiasis. However, when compared to conventional minimally invasive techniques such as endoscopic retrograde cholangiopancreatography (ERCP), PTCS is characterized by greater invasiveness and a higher rate of complications. As a result, PTCS is frequently used as a supplementary treatment option. Nevertheless, it plays a unique and indispensable role in addressing hepatolithiasis. In this study, to facilitate safer clinical applications and gain a deeper understanding of PTCS-related complications, we conducted a comprehensive examination of these complications.

Methods

Research studies related to PTCS were reviewed in PubMed, Web of Science, and China National Knowledge Infrastructure (CNKI) (year range, 1952-2024). There was no restriction on language. The occurrence and management of complications at various steps of PTCS were examined and compared with those of first-line minimally invasive treatments via a tabular method. Additionally, we evaluated the feasibility of using PTCS in the context of intrahepatic bile duct stones.

Key Content and Findings

Information on the types, incidence, and treatment of complications of PTCS was extracted in this review. A total of 5,923 results were retrieved, of which 41 were excluded. The reason for exclusion was that the article was a meeting comment. The findings indicate that PTCS plays an important role in the treatment of biliary tract diseases.

Conclusions

Although PTCS is frequently used as an adjunctive therapeutic approach, its distinct utility in treating intrahepatic bile duct stones remains difficult to replace. Thus, a deeper understanding of PTCS-related complications, coupled with ongoing advancements in instrumentation, could significantly enhance the efficiency of minimally invasive gallstone management.

PERcutaneous transhepatic CHOLangioscopy using a new single-operator short cholangioscope (PERCHOL): European feasibility study

OBJECTIVES

A new short device for percutaneous endoscopic cholangioscopy was recently developed. However, feasibility and safety has not yet been evaluated. The aim of this study was to assess clinical success, technical success, and adverse events (AEs).

METHODS

This observational multicenter retrospective study included all patients who underwent percutaneous cholangioscopy using a short cholangioscope between 2020 and 2022. The clinical success, defined as the complete duct clearance or obtaining at least one cholangioscopy-guided biopsy, was assessed. The histopathological accuracy, technical success, and the AE rate were also evaluated.

RESULTS

Fifty-one patients (60 ± 15 years, 45.1% male) were included. The majority of patients had altered anatomy (n = 40, 78.4%), and biliary stones (n = 34, 66.7%) was the commonest indication. The technique was predominantly wire-guided (n = 44, 86.3%) through a percutaneous sheath (n = 36, 70.6%) following a median interval of 8.5 days from percutaneous drainage. Cholangioscopy-guided electrohydraulic lithotripsy was performed in 29 cases (56.9%), combined with a retrieval basket in eight cases (27.6%). The clinical success was 96.6%, requiring a median of one session (range 1-3). Seventeen patients (33.3%) underwent cholangioscopy-guided biopsies. There were four (7.8%) cholangioscopy-related AEs (cholangitis and peritonitis). Overall, the technical success and AE rates were 100% and 19.6%, respectively, in a median follow-up of 7 months.

CONCLUSION

Percutaneous endoscopic cholangioscopy with a new short device is effective and safe, requiring a low number of sessions to achieve duct clearance or accurate histopathological diagnosis.

Effectiveness and complication rates of percutaneous transhepatic fluoroscopy-guided management of common bile duct stones: a single-arm meta-analysis

OBJECTIVES

To perform a systematic review and meta-analysis to determine the success and complication rate of percutaneous transhepatic fluoroscopy-guided management (PTFM) for the removal of common bile duct stones (CBDS).

METHODS

A comprehensive literature search of multiple databases was conducted to identify original articles published between January 2010 and June 2022, reporting the success rate of PTFM for the removal of CBDS. A random-effect model was used to summarize the pooled rates of success and complications with 95% confidence intervals (CIs).

RESULTS

Eighteen studies involving 2554 patients met the inclusion criteria and were included in the meta-analysis. Failed or infeasible endoscopic management was the most common indication of PTFM. The meta-analytic summary estimates of PTFM for the removal of CBDS were as follows: rate of overall stone clearance 97.1% (95% CI, 95.7-98.5%); stone clearance at first attempt 80.5% (95% CI, 72.3-88.6%); overall complications 13.8% (95% CI, 9.7-18.0%); major complications 2.8% (95% CI, 1.4-4.2%); and minor complications 9.3% (95% CI, 5.7-12.8%). Egger's tests showed the presence of publication bias with respect to the overall complications (p = 0.049). Transcholecystic management of CBDS had an 88.5% pooled rate for overall stone clearance (95% CI, 81.2-95.7%), with a 23.0% rate for complications (95% CI, 5.7-40.4%).

CONCLUSION

The systematic review and meta-analysis answer the questions of the overall stone clearance, clearance at first attempt, and complication rate of PTFM by summarizing the available literature. Percutaneous management could be considered in cases with failed or infeasible endoscopic management of CBDS.

CLINICAL RELEVANCE STATEMENT

This meta-analysis highlights the excellent stone clearance rate achieved through percutaneous transhepatic fluoroscopy-guided removal of common bile duct stones, potentially influencing clinical decision-making when endoscopic treatment is not feasible.

KEY POINTS

• Percutaneous transhepatic fluoroscopy-guided management of common bile duct stones had a pooled rate of 97.1% for overall stone clearance and 80.5% for clearance at the first attempt. • Percutaneous transhepatic management of common bile duct stones had an overall complication rate of 13.8%, including a major complication rate of 2.8%. • Percutaneous transcholecystic management of common bile duct stones had an overall stone clearance rate of 88.5% and a complication rate of 23.0%.

Percutaneous Transhepatic Single-Operator Cholangioscopy-Guided Intraductal Stone Therapy in a Liver Transplant Patient With Ischemic Cholangiopathy

Ischemic cholangiopathy is a feared complication after liver transplantation. We present a 68-year-old man who is status postorthotopic liver transplant from a donation after cardiac death. His posttransplant course was complicated by the development of a biliary anastomotic stricture, ischemic cholangiopathy, biloma, recurrent cholangitis, and intrahepatic stones. Through the use of antegrade cholangioscopy with a single-operator cholangioscope (SpyGlass 2; Boston Scientific, Boston, MA) passed through a percutaneous sheath, we were able to visualize impacted stones within the left intrahepatic system and treat them using electrohydraulic lithotripsy for stone fragmentation and removal.

Percutaneous transhepatic laser lithotripsy for intrahepatic cholelithiasis: A technical report

Advances in interventional radiology have seen the adaptation of urological endoscopic laser techniques to treat biliary tract calculi. Percutaneous transhepatic biliary laser lithotripsy provides an effective alternative procedure for the management of intrahepatic or conventionally refractory choledocholithiasis which would otherwise require invasive and high-risk surgical intervention. Several small studies have validated the procedure for management in this subset of patients, with most achieving 100% calculi clearance with minimal complications. Most patients are suitable for percutaneous transhepatic biliary laser lithotripsy. Preprocedural imaging is useful for evaluating stone burden and planning percutaneous access. Holmium lasers are commonly used and act by vaporising water particles on and in the calculi, fragmenting the stone via thermal expansion. A series of catheters, wires, sheaths and dilators are used to allow introduction of the choledochoscope and laser so that calculi can be targeted. Percutaneous transhepatic biliary laser lithotripsy is often used in conjunction with balloon dredging and biliary stricture dilatation. Only experienced interventionalists should perform this procedure, and users should be aware of associated hazards. Repeat percutaneous transhepatic cholangiography is routinely performed to confirm eradication of stones. Treatment of biliary calculi and obstruction is important in preventing diseases such as cholangitis and cirrhosis. For patients unsuitable for conventional treatment, percutaneous transhepatic laser lithotripsy is a safe and effective alternative when performed by experienced interventional radiologists. Preprocedural planning is imperative to procedure success.

Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.

CASE SUMMARY

We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.

CONCLUSION

PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

Safety, diagnostic accuracy and therapeutic efficacy of digital single-operator cholangioscopy

Background

Digital single-operator cholangioscopes (digital SOCs), equipped with an improved image quality, have been recently introduced.

Objective

The aim of this study is to evaluate the safety and diagnostic and therapeutic efficacy of digital SOCs (Spyglass™ DS).

Methods

Sixty-seven digital SOC procedures performed between 2015 and 2017 were retrospectively analyzed.

Results

The most frequent indications for examination were indeterminate biliary strictures (61.2%) and biliary stone disease (23.9%). In 25 patients (37.3), visual findings predicted malignancy with a sensitivity of 88.9%, a specificity of 97.6%, a positive predictive value (PPV) of 96.0% and a negative predictive value (NPV) of 92.9%. For histological analysis, forceps biopsies were performed in 29 patients (43.2%). Compared with visual findings, forceps biopsies yield a lower diagnostic efficacy in diagnosing malignancy (sensitivity 62.5%, specificity 90.0%, PPV 90.9%, NPV 60.0%). Therapeutic interventions were performed in 19 patients with a technical success rate of 89.4%. Adverse events were observed in 17 patients (25.4%). Of these, 11 patients (16.4%) suffered from severe adverse events (pancreatitis, cholangitis or major bleeding), which led to a prolonged hospital stay.

Conclusion

Digital SOCs have excellent diagnostic and therapeutic efficacies, but are accompanied by high rates of adverse events; therefore, physicians should use digital SOCs in carefully selected cases.

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones

Cholelithiasis is a kind of common and multiple diseases. In recent years, traditional laparotomy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. (1) For intrahepatic bile duct stones, the operation may be selected by laparoscopic liver resection, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy. (2) For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows: laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

Choledocholithiasis: Evaluation, Treatment, and Outcomes

Choledocholithiasis occurs in up to approximately 20% of patients with cholelithiasis. A majority of stones form in the gallbladder and then pass into the common bile duct, where they generate symptoms, due to biliary obstruction. Confirmatory diagnosis of choledocholithiasis is made with advanced imaging, including magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography (ERCP). Treatment varies locally; however, ERCP with sphincterotomy is most commonly employed with a high degree of success. Difficult anatomy and difficult stone burden require advanced surgical, endoscopic, and percutaneous techniques to extract or expel biliary stones. Knowledge of these treatment strategies will optimize outcomes.

Strategy of minimally invasive surgery for patients with intrahepatic and extrahepatic bile duct stones

Cholelithiasis is a common, frequently occurring disease. In recent years, traditional laparotomy is challenged by minimally invasive surgery. Through literature review combined with our practical experience based on the present situation of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones, a strategy for improving the effectiveness of minimally invasive treatment is discussed as follows: (1) For intrahepatic bile duct stones, laparoscopic hepatectomy, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy can be chosen according to the indications; (2) For concomitant gallstones and common bile duct stones, laparoscopic cholecystectomy (LC) + endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation (EPBD), LC + laparoscopic transcystic common bile duct exploration (LTCBDE), LC + LCBDE + T tube drainage or primary suture can be chosen according to the indications; (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross-section, LCBDE, EST, or percutaneous transhepatic cholangioscopic lithotripsy could be chosen according to the indications. Reasonable selection of minimally invasive treatments according to this strategy is of great significance to improve the therapeutic effect for intrahepatic and extrahepatic bile duct stones.

Advances in Therapeutic Cholangioscopy

Nowadays, cholangioscopy is an established modality in diagnostic and treatment of pancreaticobiliary diseases. The more widespread use and the recent development of new technologies and accessories had renewed the interest of endoscopic visualization of the biliary tract, increasing the range of indications and therapeutic procedures, such as diagnostic of indeterminate biliary strictures, lithotripsy of difficult bile duct stones, ablative techniques for intraductal malignancies, removal of foreign bodies and gallbladder drainage. These endoscopic interventions will probably be the last frontier in the near future. This paper presents the new advances in therapeutic cholangioscopy, focusing on the current clinical applications and on research areas.