Balloon dilation of intrahepatic biliary strictures for percutaneous extraction of residual intrahepatic stones

Intrahepatic ductal strictures in cholangiohepatitis present an obstacle to successful removal of retained ductal stones via T-tube tracts. We studied the effectiveness of stricture dilatation for stone removal. Fifteen patients with intrahepatic gallstones retained behind strictures underwent balloon dilatation of their strictures to allow stone extraction. All had prior surgical T-tube placement allowing percutaneous access. Balloon dilatation was successful in reducing or eliminating strictures in 86.7% (13 of 15 patients), and complete stone extraction after the successful dilatation was possible in 76.9% (10 of 13 patients). The reasons for failure were impacted stones and acute ductal angulation which prevented passage of catheters. It is concluded that balloon dilatation of intrahepatic biliary strictures is an effective adjunct for extraction of intrahepatic biliary calculi associated with recurrent pyogenic cholangiohepatitis.     

嵌顿性胆总管或胆囊管结石的介入性综合治疗

目的 评价多种介入性取石技术综合应用于１组患有嵌顿性胆管结石,且被视为手术高危病人的治疗效果。方法 ９例（男２例,女７例,平均年龄５０．７岁）患者中,６例曾有接受内窥镜下取石失败或手术直视下取石再复发的病史;在发生部位上,计有７例胆总管结石,１例胆囊管结石,１例胆总管合并胆囊管残端结石;多发性结石５例,单发性结石４例;最大结石直径约为３．０ｃｍ。在处理方法上,建立经皮肝胆管和内窥镜下经十二指肠逆向     

Percutaneous nephrostomy in conjunction with ESWL in treatment of nephrolithiasis

The use of percutaneous nephrostomies (PCNs) in 1456 patients (1660 kidneys) treated with extracorporeal shock-wave lithotripsy (ESWL) was evaluated. In this group, 138 PCNs (130 patients) were performed in 133 kidneys. Forty-seven percent of PCNs were placed in patients with staghorn calculi; 24% were for stones in the renal pelvis, and 20% for ureteral stones. The most common indication for PCN was fever and obstruction (57%). In 15%, the indications were failure to decompress an obstructed system from a retrograde direction, clogged double-J ureteral stents, and perforation of the ureter. Prophylactic PCN placement in the treatment of staghorn calculi and large stones in the renal pelvis accounted for 12%. Five percent were placed for miscellaneous other reasons, and for 11% there was no documentation of the indication because they were placed before the patients came to our center. Localization of the collecting system for optimal placement of PCN is unique in ESWL patients because the residual stone fragments provide natural contrast. This eliminates the need for administration of contrast material in 50% of the patients. Twenty-six percent of PCN tracts were subsequently used for other procedures (e.g., percutaneous nephrolithotomy, fragment irrigation, ureteral stone manipulation). Bleeding complications from PCN occurred in 7%. Other minor complications occurred in 12% of cases. PCN is a useful adjuvant to ESWL treatment of kidney stones. Although its major use is to relieve urinary tract obstruction, it is also used as a preliminary step in planning other percutaneous interventional procedures. This is particularly the case in the treatment of large bulky stones in the renal pelvis and staghorn calculi.     

Percutaneous Treatment of Extrahepatic Bile Duct Stones Assisted by Balloon Sphincteroplasty and Occlusion Balloon

Objective

To describe the technical feasibility and usefulness of extrahepatic biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing.

Materials and Methods

Fifteen patients with extrahepatic bile duct stones were included in this study. Endoscopic stone removal was not successful in 13 patients, and two patients refused the procedure due to endoscopy phobia. At first, all patients underwent percutaneous transhepatic biliary drainage (PTBD). A few days later, through the PTBD route, balloon assisted dilatation for common bile duct (CBD) sphincter was performed, and then the stones were pushed into the duodenum using an 11.5 mm occlusion balloon. Success rate, reason for failure, and complications associated with the procedure were evaluated.

Results

Eight patients had one stone, five patients had two stones, and two patients had more than five stones. The procedure was successful in 13 patients (13/15). In 12 of the patients, all stones were removed in the first trial. In one patient, residual stones were discovered on follow-up cholangiography, and were subsequently removed in the second trial. Technical failure occurred in two patients. Both of these patients had severely dilated CBD and multiple stones with various sizes. Ten patients complained of pain in the right upper quadrant and epigastrium of the abdomen immediately following the procedure, but there were no significant procedure-related complications such as bleeding or pancreatitis.

Conclusion

Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an effective, safe, and technically feasible procedure which can be used as an alternative method in patients when endoscopic extrahepatic biliary stone removal was not successful.     

Computed tomography of choledocholithiasis

Computed tomography (CT) correctly diagnosed common bile duct stones in 19 (90%) of 21 surgically proven cases. CT demonstrated calculi in all 13 patients with calcium bilirubinate common duct stones and six of eight patients with predominantly cholesterol stones. There were two false-negative diagnoses in patients with cholesterol calculi scanned at 1 cm intervals. Cholesterol stones are nearly isodense with bile and may be difficult to visualize in the common duct by routine scanning techniques. There are three suggestive CT features of cholesterol common duct calculi: (1) abrupt termination of the distal common bile duct without an obstructing mass, (2) a faint rim of increased density along the peripheral margin of a low-density calculus, and (3) mottled areas of increased density centrally within a calculus elevating its CT number above values for normal bile. Modification of scanning technique to obtain high-resolution images of the extrahepatic biliary tree is stressed to optimize visualization of the above findings.     

Percutaneous removal of retained intrahepatic stones with a pre-shaped angulated catheter: review of 96 patients.

Intrahepatic biliary stone disease is prevalent in East Asia and there is a high frequency of retained intrahepatic stones after surgical treatment. Percutaneous removal of retained intrahepatic stones with a pre-shaped angulated catheter and a Dormier basket was attempted in a group of 96 patients who had a T-tube. Seventy-six had multiple intrahepatic stones, confined to one hepatic lobe in 52 patients. Stones were exclusively intrahepatic in 68 cases. Biliary strictures were present in 92 cases (95.8%). A combination of techniques was used including pre-shaped angulated catheters, irrigation suction, balloon dilatation of strictures, crushing of large stones and extracorporeal shockwave lithotripsy. Retained stones were completely removed in 48 cases, and incompletely removed in 22 cases. The overall success rate was 72.9%. There were only minor complications. No mortality or significant morbidity requiring hospitalization occurred. Angular deformity, stricture of bile ducts and impacted stones were the most frequent factors responsible for failure or incomplete removal of retained stones. Fluoroscopically guided percutaneous interventional procedures with a pre-shaped angulated catheter are useful complementary procedures to surgery for patients with intrahepatic stones. The major benefits of an individually angulated catheter are safety and easy access to small peripheral bile ducts.     

Garland lecture. Percutaneous extraction of retained biliary tract stones: 661 patients

Personal experience in nonoperative biliary stone removal through the T-tube sinus tract in 661 patients between 1972 and 1979 is reviewed. The failure rate was 5%; causes for unsuccessful stone extraction are discussed. Special maneuvers are described for extraction of small stones, fragmentation of large stones, impacted stones, intrahepatic stones, and stones in the cystic duct remnant. The overall success rate of nonoperative extraction was 95%. This radiologic technique is the method of choice for removal of postoperative retained stones.     

Accuracy of magnetic resonance cholangiography compared to operative endoscopy in detecting biliary stones,a single center experience and review of literature

AIM: To compare diagnostic sensitivity, specificity and accuracy of magnetic resonance cholangiopancreatography (MRCP) without contrast medium and endoscopic ultrasound (EUS)/endoscopic retrograde cholangiopancreatography (ERCP) for biliary calculi.METHODS: From January 2012 to December 2013, two-hundred-sixty-three patients underwent MRCP at our institution, all MRCP procedure were performed with the same machinery. In two-hundred MRCP was done for pure hepatobiliary symptoms and these patients are the subjects of this study. Among these two-hundred patients, one-hundred-eleven (55.5%) underwent ERCP after MRCP. The retrospective study design consisted in the systematic revision of all images from MRCP and EUS/ERCP performed by two radiologist with a long experience in biliary imaging, an experienced endoscopist and a senior consultant in Hepatobiliopancreatic surgery. A false positive was defined an MRCP showing calculi with no findings at EUS/ERCP; a true positive was defined as a concordance between MRCP and EUS/ERCP findings; a false negative was defined as the absence of images suggesting calculi at MRCP with calculi localization/extraction at EUS/ERCP and a true negative was defined as a patient with no calculi at MRCP ad at least 6 mo of asymptomatic follow-up. Biliary tree dilatation was defined as a common bile duct diameter larger than 6 mm in a patient who had an in situ gallbladder. A third blinded radiologist who examined the MRCP and ERCP data reviewed misdiagnosed cases. Once obtained overall data on sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) we divided patients in two groups composed of those having concordant MRCP and EUS/ERCP (Group A, 72 patients) and those having discordant MRCP and EUS/ERCP (Group B, 20 patients). Dataset comparisons had been made by the Student’s t-test and χ² when appropriate.RESULTS: Two-hundred patients (91 men, 109 women, mean age 67.6 years, and range 25-98 years) underwent MRCP. All patients attended regular follow-up for at least 6 mo. Morbidity and mortality related to MRCP were null. MRCP was the only exam performed in 89 patients because it did show only calculi into the gallbladder with no signs of the presence of calculi into the bile duct and symptoms resolved within a few days or after colecistectomy. The patients remained asymptomatic for at least 6 mo, and we assumed they were true negatives. One hundred eleven (53 men, 58 women, mean age 69 years, range 25-98 years) underwent ERCP following MRCP. We did not find any difference between the two groups in terms of race, age, and sex. The overall median interval between MRCP and ERCP was 9 d. In detecting biliary stones MRCP Sensitivity was 77.4%, Specificity 100% and Accuracy 80.5% with a PPV of 100% and NPV of 85%; EUS showed 95% sensitivity, 100% specificity, 95.5% accuracy with 100% PPV and 57.1% NPV. The association of EUS with ERCP performed at 100% in all the evaluated parameters. When comparing the two groups, we did not find any statistically significant difference regarding age, sex, and race. Similarly, we did not find any differences regarding the number of extracted stones: 116 stones in Group A (median 2, range 1 to 9) and 27 in Group B (median 2, range 1 to 4). When we compared the size of the extracted stones we found that the patients in Group B had significantly smaller stones: 14.16 ± 8.11 mm in Group A and 5.15 ± 2.09 mm in Group B; 95% confidence interval = 5.89-12.13, standard error = 1.577; P < 0.05. We also found that in Group B there was a significantly higher incidence of stones smaller than 5 mm: 36 in Group A and 18 in Group B, P < 0.05.CONCLUSION: Major finding of the present study is that choledocholithiasis is still under-diagnosed in MRCP. Smaller stones (< 5 mm diameter) are hardly visualized on MRCP.     

Sonographic and computed tomographic evaluation of intrahepatic calculi

Intrahepatic calculi in non-Asian patients were studied by sonography and computed tomography (CT). Three patients were studied by CT cholangiography also. In two cases, the calculi were consecutive to Caroli disease, and in two others, the biliary stones were formed proximal to a stenosis of a previous surgical anastomosis. Five patients spontaneously developed intrahepatic calculi. All sonograms were abnormal. Image specificity was good, even when bile ducts were not dilated, if appropriate technique allowed identification of a double-arc-shadow pattern. Sonography strongly suggested the diagnosis in eight patients and was nonspecific in only one. On CT, calculi had various densities, and they were not visible in two patients. CT cholangiography was not particularly helpful. Finally, CT added little more information when performed after sonography. Both examinations strongly underestimate the number of stones, and direct cholangiography remains indicated if surgery is planned.     

3D-SPACE联合3D-TSERT序列扫描技术在MRCP诊断结石中的价值

目的:评估可变翻转角的三维快速自旋回波（3D-SPACE）联合三维快速恢复快速自旋回波（3D-TSERT）序列扫描技术在磁共振胰胆管成像（MRCP）诊断结石中的价值。方法:选取2019年1月至9月于徐州市中心医院确诊为胰腺和胆道结石的168例患者的临床资料进行回顾性研究,其中男性93例、女性75例,年龄24~70 （4...     

Treatment of bile duct stones by laser lithotripsy: results in 12 patients.

We used a pulsed tunable dye laser (operating at 60 mJ per pulse, 504-nm wavelength) to fragment large (0.8-4.5 cm) stones retained in the hepatic ducts or common bile duct in 12 patients after cholecystectomy. Attempts to extract stones via a T-tube or endoscope had been unsuccessful in all patients. In nine of 12 patients, all stone fragments were successfully eliminated during the initial treatment. In one patient, fragmentation occurred but debris remained, requiring endoscopic stenting. Pseudomonas sepsis developed in this patient 30 days after the procedure and was treated by extraction of the stone fragments. Fragments remaining after lithotripsy were cleared at the same sitting by using saline flushing or endoscopic or percutaneous basket extraction. In two of 12 patients, the treatment was unsuccessful because of laser malfunction. The treatment was performed without complications, except for clinically insignificant hyperamylasemia, which occurred in two patients. Our experience suggests that laser lithotripsy offers a safe alternative for nonsurgical treatment of large retained biliary stones for patients in whom traditional treatments have failed.     

Intracorporeal biliary lithotripsy

Most bile duct calculi can be removed with standard percutaneous or endoscopic techniques. Very large stones are the most common cause for failure. Intracorporeal lithotripsy, and EHL in particular, can be used safely in either the biliary tree or gallbladder to fragment these large stones and allow percutaneous removal or passage. Intracorporeal EHL requires direct vision to prevent damage to the bile duct mucosa. Intracorporeal laser lithotripsy may offer some safety advantages, but the laser requires much more expensive equipment than intracorporeal EHL. Additional studies are needed to determine the technique that is better in each circumstance.     

Effectiveness and safety of balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi

OBJECTIVE: The purpose of this study was to describe a technique for percutaneous bile duct stone clearance by pushing the stones into the small bowel after balloon dilation of the papilla. SUBJECTS AND METHODS: During a 2-year period, 38 patients were treated percutaneously for stones in the biliary tree. Twenty-one patients were treated through a T tube or transcystic tract. Seventeen patients were treated through a transhepatic tract. Twenty-three patients had one stone each. Eight patients had two stones, and seven patients had three or more calculi. Stone size ranged from 3 to 16 mm in diameter (mean size, 6.7 nm). Balloon diameter based on the transverse diameter of the stones ranged from 7 to 18 mm (mean, 6.7 mm). An 11.5-mm occlusion balloon was used for pushing the stones through a 7- to 9-French vascular introducer. A catheter was left in the common bile duct from 1 to 6 days for external drainage. RESULTS: The technique was successfully used for clearance of stones in 36 (94.7%) of the 38 patients. With 29 patients, the procedure was performed with only one attempt. Two attempts were necessary for five patients, and three attempts were necessary for four patients. Two major complications were cholangitis and biliary pleural effusion. No deaths were related to the procedure. CONCLUSION: Percutaneous bile duct stone clearance by dilation of the papilla and evacuation of the stones in an antegrade fashion with an occlusion balloon is a safe and effective technique. It can be an alternative to basketing stones in selected patients.     

Percutaneous removal of biliary stones

Since 1983 we have performed percutaneous treatment of biliary lithiasis in 97 patients. Previous retrograde endoscopic procedures were incomplete or infeasible in all patients. Immediate results were excellent resulting in complete resolution of lithiasis in 89 of 97 patients (92%). In 4 patients (4%) partial success was obtained (symptoms subsided although there were nonobstructing residual stones). Percutaneous treatment failed in 1 patient (1%). Three patients died. Complications occurred in 14 of 97 patients (14%) and mortality at 30 days was 3%. Long-term results were evaluated in 71 patients who had at least a 6-month follow-up (mean 31 months and range 6–78 months). Eight of 71 patients (11%) had recurrence of stones and 7 of these were successfully retreated transhepatically. Percutaneous removal of biliary stones is efficacious because it has a high cure rate, a low complication rate, and a mortality rate that compares favorably to that of surgery even though the patients are usually older and in poorer general condition.     

Sonographic evaluation of renal stones treated by extracorporeal shock-wave lithotripsy

Real-time sonography was performed on 94 patients the day before and at 24 and 48 hr after extracorporeal shock-wave lithotripsy (ESWL) therapy. The ability of sonography to detect renal stones before ESWL, changes in the calculi after ESWL, and the occurrence of pre- and post-ESWL hydronephrosis was evaluated. Abdominal radiographs and linear renal tomography were used as the standard of comparison. Six other patients had sonography only either before or after ESWL. One hundred patients had a total 105 kidneys treated; 18 kidneys with more than three stones were not included. The other 87 kidneys had 102 stones evaluated by sonography before having ESWL; 66 stones (65%) were identified and 36 were not. Of those calculi not seen, 10 were less than or equal to 5 mm in diameter. Nineteen of the other 26 stones were in the ureter or at the ureteropelvic junction. Comparison of sonograms of 80 kidneys obtained before and after ESWL revealed no change in 37 (46%), more stones or fragments detected in 23 (29%), fewer stones or a change in location in 12 (15%), and an apparent decrease in the size of the original stone in eight (10%). Hydronephrosis was detected by pre-ESWL sonography in 16 kidneys (20%) and was noted to develop after ESWL in 20 (31%) of the 64 other kidneys. These results indicate that the ability of sonography to detect renal calculi is related not only to stone size but also to location. The clinical significance of pre- and post-ESWL hydronephrosis found by sonography must be considered in conjunction with the patient's symptoms, laboratory data, and other radiographic studies. Therefore, the routine use of sonography in the post-ESWL patient does not seem warranted.     

Gallstone recurrence after cholecystolithotomy

Surgical cholecystostomy is performed often at our institution for emergent management of acute calculous cholecystitis in high-risk elderly patients. Gallstones are removed either during surgery or by subsequent radiologic manipulation. Most such patients do not undergo subsequent cholecystectomy. The frequency of gallbladder stone and/or biliary symptom recurrence was studied in 63 patients who had undergone successful cholecystolithotomy. Follow-up examinations in 48 of these patients, performed at a mean of 18 +/- 12 months after surgery, showed recurrence of gallstones in 13 patients (27%). This included 12 of 38 patients who had follow-up sonograms and one of two cadavers that underwent autopsy. None of eight patients who had a subsequent cholecystectomy had recurrent stones. Two of 17 patients studied within 1 year of cholecystolithotomy had recurrent calculi, as did six of 21 patients studied at 1-2 years, four of five patients studied at 2-3 years, and one of five patients studied at 3-4 years. Biliary symptoms were assessed in 46 of the 48 patients who had follow-up examinations (two patients died) and in the 15 other patients who had undergone successful cholecystolithotomy. Recurrent or residual symptoms were present in seven (11%) of 61 patients, including three of the 13 patients with recurrent calculi. Six of these seven patients underwent further hospital treatment. These results confirm the anticipated high frequency of stone recurrence after cholecystolithotomy. However, because most patients with recurrent stones were asymptomatic, routine interval cholecystectomy may not be necessary.     

Stability of Retained Inferior Vena Cava Filter Fragments after Filter Removal

PurposeTo assess the stability and outcome of fractured inferior vena cava (IVC) filter fragments that are retained in patients after IVC filter removal.Materials and MethodsA retrospective analysis was conducted on all patients at a single tertiary referral center between May 2005 and June 2020 with fractured IVC filters where fragment(s) were retained after removal of the main filter body. IVC filter fragment stability was assessed by a clinician review of computed tomography images, chosen from available radiologic studies, to best visualize the fragments. Data collected included filter type, fragment location, duration of fragment follow-up, fragment stability in location, and further fragment fracture or clinical sequelae.ResultsSeventy-seven patients with retained IVC filter fragment(s) after complex filter removal were identified. Of this, 37 patients (14 men, 23 women) were deemed to have adequate imaging follow-up to assess positional stability of the retained fragments, whereas the remainder were excluded from further analysis. Excluding fractured foot processes, 51 separate filter fragments were retrospectively identified and followed for a median duration of 726 days (interquartile range, 843 days; range, 28–3353 days). Filter designs producing the studied fragments included Celect, G2, Recovery, Günther, OptEase, Meridian, and G2X/Eclipse. In all, 50 of 51 (98%) fragments were found to be unchanged in position during their respective intervals of observation. One fragment displayed a rotational change without migrating from its original location. No further fragment fractures or clinical sequelae were observed among the group.ConclusionsWhen asymptomatic, retained IVC filter fragments are predominantly stable and can be safely followed on an intermediate-term basis.     

Extracorporeal shock-wave lithotripsy in the management of bile duct stones

Extracorporeal shock-wave lithotripsy (ESWL) was performed in 16 patients with bile duct stones. Dornier HM3 water-bath equipment (Dornier Medical Systems, Marietta, GA) was used in all procedures. All patients had either a T-tube or a nasobiliary, cholecystostomy, or transhepatic biliary drainage tube in place at the time of the lithotripsy. In 12 patients, the indication for ESWL was the failure of or anticipated difficulty with basket extraction of the stones, either via a T-tube tract or by means of endoscopic sphincterotomy. In the other four patients, ESWL was performed immediately after retained stones were found on a postoperative cholangiogram, even though no difficulty was anticipated in removing the stones by means of basket extraction. In 15 (94%) of the 16 patients, the stones were successfully fragmented. The fragments passed spontaneously in nine patients but had to be removed by basket in five patients. In one patient, the fragments could not be extracted by basket. The number of ESWL shocks used in a single session ranged from 525 to 3200. Three patients had two ESWL sessions. No significant complications were observed. ESWL is a successful method for the management of patients with bile duct stones when used in conjunction with other nonsurgical techniques. It was also the only treatment required in 56% of our patients.     

Percutaneous lithotripsy of staghorn calculi

Eleven cases of staghorn calculi managed by percutaneous lithotripsy were reviewed. Ten of 11 cases were successful, and 70% of the successfully treated patients were discharged free of any renal stones. The percentage of patients discharged with residual stone fragments was higher than those with either percutaneously managed nondendritic calculi or surgically treated staghorn calculi. The complication rate was higher than for nonbranched stones managed percutaneously and was comparable to that for surgically removed dendritic calculi. Hospital stay averaged 18 days, equal to that for staghorn calculi treated by conventional surgical approach, but considerably longer than for nonbranched stones. Overall results more closely approximated those for surgical removal of staghorn calculi than those for percutaneous removal of nonbranched calculi. However, the principal advantage of percutaneous lithotripsy of staghorn calculi over surgical management is the significant reduction in convalescence after discharge from the hospital.     

The value of drip infusion cholangiography using multidetector-row helical CT in patients with choledocholithiasis

The purposes of this study were to investigate the feasibility of drip infusion cholangiography computed tomography (CTCh) for choledocholithiasis and to compare the detection of the stone on CTCh with that of MR cholangiopancreatography (MRCP). CTCh examinations were performed after infusion of intravenous biliary contrast material (iotroxic acid meglumine, 100 ml) for patients with suspected biliary diseases and were reconstructed to maximum intensity projection (MIP) and multiplanar reformation (MPR). Of 432 patients who underwent CTCh, we identified 15 who underwent surgery or cholangioscopic removal for choledocholithiasis and 32 patients who underwent cholecystectomy due to cholecystolithiasis. Their MRCP images were compared with the CTCh images. The sensitivity and specificity of CTCh for detecting choledochal stones were 87% and 96% whereas those of MRCP were 80% and 88%. The sensitivity and specificity of CTCh for detecting gallstones were 78% and 100% whereas those of MRCP were 94% and 88%. CTCh allowed high sensitivity and specificity for detecting choledochal stones but diminished the detection for cholecystolithiasis compared with MRCP.