Percutaneous Transhepatic Cholangioscopy in Bilioenteric Anastomosis Stricture

Atlas for Cholangioscopy and Cholecystoscopy: A Primer for Diagnostic and Therapeutic Endoscopy in the Biliary Tree and Gallbladder

Percutaneous endoscopy of the biliary system (cholangioscopy) and gallbladder (cholecystoscopy) has significantly impacted diagnostic and therapeutic approaches to many diseases in interventional radiology, overcoming previous challenges related to scope size and rigidity. The current endoscopes offer enhanced maneuverability within narrow tubular structures such as bile ducts. Before endoscopy, reliance on 2D imaging modalities limited real-time visualization during percutaneous procedures. Percutaneous endoscopy provides 3D perspectives, enabling a better appreciation of normal structures, targeted biopsy of lesions, and accurate deployment of therapeutic interventions. This review aims to explore percutaneous endoscopic findings across various biliary and gallbladder pathologies.

Management of anastomotic biliary stricture through utilizing percutaneous transhepatic cholangioscopy

AIM

Occurrence of anastomotic biliary stricture (AS) remains an essential issue following hepatobiliary surgeries, and percutaneous transhepatic cholangioscopy (PTCS) has great therapeutic significance in handling refractory AS for patients with altered gastrointestinal anatomy after cholangio-jejunostomy. This present study aimed to investigate feasibility of PTCS procedures in AS patients for therapeutic indications.

MATERIALS AND METHODS

This study was a single-center, retrospective cohort study with a total number of 124 consecutive patients who received therapeutic PTCS due to AS. Clinical success rate, required number, and adverse events of therapeutic PTCS procedures as well as patients survival state were reviewed.

RESULTS

These 124 patients previously underwent choledochojejunostomy or hepatico-jejunostomy, and there was post-surgical altered gastrointestinal anatomy. Overall, 366 therapeutic PTCS procedures were performed for these patients through applying rigid choledochoscope, and the median time of PTCS procedures was 3 (1-11). Among these patients, there were 34 cases (27.32%) accompanied by biliary strictures and 100 cases (80.65%) were also combined with biliary calculi. After therapeutic PTCS, most patients presented with relieved clinical manifestations and improved liver functions. The median time of follow-up was 26 months (2-86 months), and AS was successfully managed through PTCS procedures in 104 patients (83.87%). During the follow-up period, adverse events occurred in 81 cases (65.32%), most of which were tackled through supportive treatment.

CONCLUSION

PTCS was a feasible, safe and effective therapeutic modality for refractory AS, which may be a promising alternative approach in clinical cases where the gastrointestinal anatomy was changed after cholangio-jejunostomy.

Percutaneous Transhepatic Cholangioscopy Interventions-Updates

Percutaneous transhepatic cholangioscopy (PTCS) was initially described around the same time that peroral cholangioscopy (POSC) was developed. The cited utility attributed to PTCS is the ability to be utilized in the subset of patients with surgical proximal bowel anatomy, often precluding the use of traditional POSC. However, since first described, PTCS use has been limited due to a lack of physician awareness and a lack of procedure-specific equipment and supplies. With recent developments of PTSC-specific equipment, there has been an expansion in the possible interventions able to be performed during PTCS, resulting in a rapid increase in clinical use. This short review will serve as a comprehensive update of the previous and more recent novel interventions now able to be performed during PTCS.

A Unique Approach to Obtaining Tissue in a Difficult to Access Indeterminate Biliary Stricture: Percutaneous Cholangioscopy and Biopsy

When evaluating biliary strictures, establishing a diagnosis can present challenges. The first-line approach of endoscopic retrograde cholangiopancreatography can often involve anatomic restrictions. Traditionally, percutaneous transhepatic cholangioscopy has been the answer for biopsies unable to be obtained with the modalities above but requires time for large tract dilation and days of sinus tract maturation to allow for a scope. We present a novel case of percutaneous digital cholangioscopy with SpyGlass DS, a small caliber scope traditionally used with endoscopic retrograde cholangiopancreatography, used for percutaneous transhepatic cholangioscopy after previous failed attempts by several different standard methods. Our case highlights a multidisciplinary approach in ultimately diagnosing malignancy.

Clinical Outcomes of Percutaneous Biliary Endoscopy: A 7-Year Single-Institution Experience

PURPOSE

To evaluate safety and effectiveness of percutaneous biliary endoscopy (PBE) performed on patients ineligible for surgery or endoscopic retrograde cholangiopancreatography.

MATERIALS AND METHODS

Retrospective review was conducted for all patients who underwent PBE at a single academic institution between June 2013 and February 2020; 39 patients underwent 58 choledochoscopy sessions, and 21 patients underwent 48 cholecystoscopy sessions. Choledochoscopy indications included stone removal (23 of 39 patients) or biliary stenosis evaluation (19 of 39 patients). Cholecystoscopy indications included calculous cholecystitis (18 of 21 patients) and symptomatic cholelithiasis (3 of 21 patients). Technical success, procedural and fluoroscopy times, and tube-free survival were assessed.

RESULTS

For all PBEs performed for stone clearance, using disposable endoscopes led to shorter mean ± SD procedural (128.7 minutes ± 56.2 vs 240.2 minutes ± 184.6; P < .01) and fluoroscopy times (10.7 minutes ± 7.9 vs 16.5 minutes ± 12.0; P = .01) than using reusable endoscopes. Increasing institutional experience was associated with reduced procedural time (β = -56.73; P < .001). Choledochoscopy technical success was 94.8% with 1 adverse event of bile duct perforation with bile leak requiring drainage. For patients with choledocholithiasis, biliary drains were removed in 14 (60.9%) patients, with a mean tube-free survival of 22.1 months ± 23.8. For cholecystoscopy, technical success was 93.8% with no adverse events. Cholecystostomy tubes were removed in 15 (71.4%) patients, with a mean tube-free survival of 7.5 months ± 8.8.

CONCLUSIONS

This study supports PBE as a safe and feasible option for nonsurgical patients or those with altered anatomy precluding endoscopic retrograde cholangiopancreatography. Moreover, PBE may result in tube-free survival.

Biliary complications in recipients of living donor liver transplantation: A single-centre study

BACKGROUND

Biliary complications (BCs) after liver transplantation (LT) remain a considerable cause of morbidity, mortality, increased cost, and graft loss.

AIM

To investigate the impact of BCs on chronic graft rejection, graft failure and mortality.

METHODS

From 2011 to 2016, 215 adult recipients underwent right-lobe living-donor liver transplantation (RT-LDLT) at our centre. We excluded 46 recipients who met the exclusion criteria, and 169 recipients were included in the final analysis. Donors’ and recipients’ demographic data, clinical data, operative details and postoperative course information were collected. We also reviewed the management and outcomes of BCs. Recipients were followed for at least 12 mo post-LT until December 2017 or graft or patient loss.

RESULTS

The overall incidence rate of BCs including biliary leakage, biliary infection and biliary stricture was 57.4%. Twenty-seven (16%) patients experienced chronic graft rejection. Graft failure developed in 20 (11.8%) patients. A total of 28 (16.6%) deaths occurred during follow-up. BCs were a risk factor for the occurrence of chronic graft rejection and failure; however, mortality was determined by recurrent hepatitis C virus infection.

CONCLUSION

Biliary complications after RT-LDLT represent an independent risk factor for chronic graft rejection and graft failure; nonetheless, effective management of these complications can improve patient and graft survival.

Clinical application of laparoscopy combined with choledochoscopy in patients with bilioenteric anastomotic stricture with access via the jejunal loops

Objective

Bilioenteric anastomotic stricture is a serious complication following choledochojejunostomy. Some patients develop intrahepatic lithiasis and biliary tract infection without dilation of the intrahepatic bile duct. The present study was performed to investigate the safety and efficacy of laparoscopy combined with choledochoscopy in patients with bilioenteric anastomotic stricture with access via the jejunal loops.

Methods

The data of 10 patients (7 men and 3 women; mean age, 60.8 ± 9.7 years; age range, 51–76 years) with potential bilioenteric anastomotic stricture without dilation of the intrahepatic bile duct from January 2015 to December 2019 were retrospectively reviewed.

Results

All 10 patients underwent surgery, and their clinical parameters were recorded. The mean surgery time was 181.5 ± 35.4 minutes, and the mean estimated blood loss was 32.0 ± 15.5 mL. No patients developed serious complications during the perioperative period. The short-term outcome analysis at 12 months indicated that the stenosis had been effectively dilated and that the liver function had improved.

Conclusions

The results of the present study demonstrated that laparoscopy combined with choledochoscopy with access via the jejunal loops is feasible in the treatment of bilioenteric anastomotic stricture and intrahepatic lithiasis.

Efficacy and Safety of Percutaneous Transhepatic Cholangioscopy with the Spyglass DS Direct Visualization System in Patients with Surgically Altered Anatomy: A Pilot Study

Background/Aims

Percutaneous transhepatic cholangioscopy (PTCS) is used for the diagnosis and treatment of biliary diseases in patients with failed endoscopic retrograde cholangiopancreatography, particularly those with surgically altered anatomy. However, few studies are available on the clinical use of Spyglass DS direct visualization system (SpyDS)-assisted PTCS. This study aimed to assess the efficacy and safety of SpyDS-assisted PTCS in patients with surgically altered anatomy, particularly those with a Roux-en-Y reconstruction.

Methods

Thirteen patients (six women, median age 71.4 years [range, 53 to 83 years]) with surgically altered anatomy (four Roux-en-Y choledochojejunostomies, seven Roux-en-Y hepaticojejunostomies, and two Roux-en-Y esophagojejunostomies) who underwent SpyDS-assisted PTCS between January 2019 and August 2020 were included and the data was acquired by retrospectively reviewing electronic medical record.

Results

A total of 19 SpyDS-assisted PTCS procedures were performed in the 13 patients eight had bile-duct stones, and five had biliary strictures. All SpyDS-assisted PTCS procedures were successfully performed. The total procedure time was 42.42±18.0 minutes (mean±standard deviation). Bile duct clearance was achieved in all bile duct stone cases after a median of 2 (range, 1 to 3) procedures. In the five biliary stricture cases, the results of SpyBite forceps-guided targeted biopsy were consistent with adenocarcinoma (100% accuracy). The median hospitalization duration was 20 days (range, 14 to 30 days). No procedure-related morbidity or mortality occurred.

Conclusions

SpyDS-assisted PTCS may be a safe, feasible, and effective procedure for the diagnosis and treatment of biliary diseases in patients with surgically altered anatomy, particularly in those with the Roux-en-Y reconstruction requiring a percutaneous approach. However, our findings need to be validated in further studies.

One-step percutaneous transhepatic cholangioscopic lithotripsy in patients with choledocholithiasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) may be inappropriate for most patients with choledocholithiasis. This study aimed to evaluate one-step percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of patients with choledocholithiasis who could not undergo ERCP (e.g., failed ERCP, altered anatomy, and/or contra-indications).

METHOD

This was a retrospective single-centre series of 67 patients who underwent choledocholithiasis between November 2015 and March 2018: 35 with one-step PTCSL (Group A) and 32 with laparoscopic common bile duct (CBD) exploration (Group B).

RESULTS

Compared with Group B, Group A showed shorter duration of operation, length of stay in the hospital, postoperative hospital stay, postoperative drainage time, and time to oral intake (all P<0.05). Intraoperative blood loss, costs, conversion to open surgery (one in group A vs. seven in group B; P=0.023), and bile leakage (none in group A vs. four in group B; P=0.047) were lower in Group A than in Group B. There were no significant differences between the two groups regarding the intraoperative clearance rate, ultimate clearance rate, and several postoperative complications.

CONCLUSION

One-step PTCSL could be an alternative for patients with choledocholithiasis, especially when ERCP is not feasible.

Endoscopic biliary therapy in the era of bariatric surgery

There is an increasing demand and availability of bariatric surgery, with a range of procedures performed, some leading to altered upper gastrointestinal anatomy. The patient population undergoing bariatric surgery is also at increased risk of gallstones and biliary stone disease. Endoscopy (ie, endoscopic retrograde cholangiopancreatography) is the cornerstone of management of biliary stone disease, but may be challenging after bariatric surgery. In this review the endoscopic, surgery assisted, or percutaneous options that may be considered are discussed, based on the details of surgical anatomy and available expertise.

A case of a smooth transition to subsequent percutaneous transjejunal biliary intervention for hepatolithiasis after biliary reconstruction by adding jejunostomy during an emergency operation for perforation due to balloon-assisted endoscopy

Treatments for hepatolithiasis include peroral endoscopy, percutaneous cholangioscopy, and surgery. Balloon-assisted endoscopic retrograde cholangiopancreatography (BAERCP) has been widely performed in recent years for patients with hepatolithiasis after biliary reconstruction. However, accidental bowel perforation caused by BAERCP may need emergency surgery. Here, we describe a 77-year-old Japanese woman diagnosed with acute cholangitis due to hepatolithiasis after biliary reconstruction (a biliary diversion operation for pancreaticobiliary maljunction). She underwent BAERCP for treatment of hepatolithiasis, however, a small-bowel perforation occurred. She underwent an emergency operation to suture the perforation and add a catheter jejunostomy. She had no postoperative complications after surgery and was discharged 11 days after surgery. One month later, she was readmitted and underwent percutaneous transjejunal cholangioscopy-guided lithotripsy with complete removal of the calculi. Although endoscopists should be careful to avoid small-bowel perforation during BAERCP, if perforation occurs, addition of a catheter jejunostomy during emergency surgery can be easily transitioned to subsequent treatment of the hepatolithiasis.

Cholangiolithiasis postliver transplantation: Successful treatment utilizing percutaneous transhepatic cholangioscopy and laser lithotripsy

Liver transplant is a risk factor for the development of cholangiolithiasis and choledocholithiasis. While usually addressed by endoscopic techniques, percutaneous transhepatic cholangioscopy combined with laser lithotripsy can be considered a suitable alternative option in select patients.

A 29-year-old male with a 27-year history of liver transplant presented with new onset of persistent pain localized to the lower abdomen 9 days after a liver biopsy. Abdominal CT scan and MRCP showed large calculi expanding intra- and extrahepatic bile ducts. All intrahepatic ductal calculi were removed after 2 sessions of laser lithotripsy and basket retrieval, while common hepatic duct calculi were anterogradely swept into the jejunum after balloon cholangioplasty of the hepaticojejunal anastomosis. No major procedure-related complications were seen.

Percutaneous transhepatic cholangioscopy and choledochoscopy with laser lithotripsy is a minimally invasive and efficient technique for removal of intra- and extrahepatic bile duct stones postliver transplantation.

Endoscopic management of anastomotic stricture after living-donor liver transplantation

The most effective and fundamental treatment for end-stage liver disease is liver transplantation. Deceased-donor liver transplantation has been performed for many of these cases. However, living-donor liver transplantation (LDLT) has emerged as an alternative because it enables timely procurement of the donor organ. The success rate of LDLT has been improved by development of the surgical technique, use of immunosuppressant drugs, and accumulation of post-transplantation care experience. However, the occurrence of biliary stricture after LDLT remains a problem. This article reviews the pathogenesis, diagnosis, endoscopic management, and long-term outcomes of post-liver transplantation biliary stricture, with a focus on anastomotic stricture.

Minimally invasive treatment of intrahepatic cholangiolithiasis after stricture of hepaticojejunal anastomosis

The aim of the study was to improve the results of treatment of patients with intrahepatic cholangiolithiasis for hepaticojejunostomy stricture with use of miniinvasive methods. In our centre during the period from 2002 till 2016 were treated in 58 patients with hepaticojejunostomy strictures. Thirteen patients from their was coexistant intrahepatic cholangiolithiasis. Forty-six (79.3%) patients was performed rehepaticojejunostomy. Twelve patients was performed a minimally invasive intervention such as laser recanalisation using double balloon enteroscopy (7 patients) and lithoextraction with double balloon enteroscopy (1), transhepatic cholangioscopy (2 patients) with laser lithotripsy (1), balloon dilatation of the stricture rehepaticojejunostomosis (4), lithoextraction (4), including with double balloon enteroscopy ("randevoux" procedure) (1), stenting (2). We observed several complication such as cholangitis (5); recurrent cholangiolithiasis (1); restricture of rehepaticojejunostomosis (2). Miniinvasive endoscopic techniques treatment and endobiliary correction of rehepaticojejunostomosis strictures and cholangiolithiasis have shown good results.

[Antegrade approach for cholangiolithiasis complicated by mechanical jaundice]

AIM

To improve an efficiency of surgical treatment of patients with cholelithiasis complicated by obstructive jaundice through antegrade interventional approach.

MATERIAL AND METHODS

166 patients aged from 23 to 92 years with cholangiolithiasis complicated by mechanical jaundice were enrolled. Patients were divided into 2 groups: group I (136) - retrograde endoscopic method, group II (30) - antegrade interventional approach.

RESULTS

In the first group surgical efficacy was 79.4%. Morbidity and mortality were 13% and 2% respectively. In the second group these values were 96.7%, 10% and 3% respectively.

CONCLUSION

Antegrade interventional approach for minimally invasive procedures is technically feasible, has the same effectiveness as the retrograde endoscopic method and also all advantages of minimally invasive techniques.