Biliary duct stones: Percutaneous transhepatic removal

Percutaneous transhepatic removal of common bile duct stones was performed 57 times in 53 patients with a success rate of 93%. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and papillotomy. A modified Dormia basket was inserted through a percutaneous transhepatic approach and the stones or fragments were advanced into the duodenum. Monooctanoin (26 patients) or methyl tertiary butyl ether (4 patients) was infused to reduce stone size or remove residual debris. The average time for complete stone removal was 8.5 days. Morbidity was 12% and mortality was 4%, results which compare favorably with those of surgery.     

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.     

Percutaneous transhepatic gallstone removal by needle tract.

A percutaneous transhepatic cholangiogram tract was used to visualize a large stone in the common duct; following the tract's dilation, the stone was crushed and partially removed. Fragments were flushed and also passed spontaneously into the duodenum. The approach described offers a feasible alternative to surgery.     

Common Bile Duct Stones Detected After Cholecystectomy: Advancement into the Duodenum via the Percutaneous Route

Purpose: To report our experience in the use of percutaneous extraction of common bile duct stones detected in the post-cholecystectomy period. Methods: Forty-two patients in whom endoscopic cannulation and/or sphincterotomy had failed or could not be done due to several reasons underwent balloon dilatation of the ampulla of Vater and subsequent advancement of the stones via the percutaneous transhepatic route or T-tube tract. Results: The procedure was successful in 42 cases. In three patients, stones were crushed in the common bile duct and pushed as fragments into the duodenum. In all cases transient adverse effects were observed. There were no major complications. All cases were checked with ultrasonography for 6 months after the procedure. Conclusion: Percutaneous extraction of common bile duct stones is an effective method of treatment with a high success rate, low complication rate and shorter hospital stay. It may serve as an alternative method in cases where endoscopic removal of stones fails.     

Percutaneous stone removal using cobra-shaped sheath and cholangioscopy for multiple hepatolithiasis with choledochoduodenal anastomotic stenosis

Management of multiple hepatolithiasis with choledochoenteral anastomotic stenosis remains difficult and time-consuming. We report a case of a 77-year-old man with severe right hypochondoralgia, treated with percutaneous transhepatic balloon dilatation of choledocoduodenal anastomotic stenosis and percutaneous stone removal using 8Fr. cobra-shaped sheath and cholangioscopy. Hilar hepatic stones were pushed out into the duodenum through the dilated anastomosis using 5Fr. balloon catheter covered with the sheath and cholangioscopy. For stones located in the left, right anterior and aberrant right posterior hepatic ducts, a guidewire and a removal balloon catheter were inserted by using the cobra-shaped sheath. Stones pulled from the intrahepatic bile ducts to the common hepatic duct were pushed out into the duodenum. Clearance of intrahepatic bile duct stones was confirmed by balloon-occluded cholangiography using the cobra-shaped sheath and 6Fr. balloon catheter. The use of cobra-shaped sheath improved percutaneous stone removal, but the procedure needs further improvement.     

Percutaneous Transhepatic Removal of Bile Duct Stones: Results of 261 Patients

Purpose

To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient.

Methods

Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14–92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones = 248 patients and hepatolithiasis = 13 patients) were included in the study. Percutaneous transhepatic cholangiography was performed, and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation.

Results

Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 major complications (6.8%), including cholangitis (n = 7), subcapsular biloma (n = 4), subcapsular hematoma (n = 1), subcapsular abscess (n = 1), bile peritonitis (n = 1), duodenal perforation (n = 1), CBD perforation (n = 1), gastroduodenal artery pseudoaneurysm (n = 1), and right hepatic artery transection (n = 1), were observed after the procedure. There was no mortality.

Conclusion

Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.     

Percutaneous Transhepatic Removal of Bile Duct Stones: Results of 261 Patients

Purpose

To determine the effectiveness of percutaneous transhepatic removal of bile duct stones when the procedure of endoscopic therapy fails for reasons of anatomical anomalies or is rejected by the patient.

Methods

Between April 2001 and May 2010, 261 patients (138 male patients and 123 female patients; age range, 14–92 years; mean age, 64.6 years) with bile duct stones (common bile duct [CBD] stones = 248 patients and hepatolithiasis = 13 patients) were included in the study. First, percutaneous transhepatic cholangiography was performed and stones were identified. Percutaneous transhepatic balloon dilation of the papilla of Vater was performed. Then stones were pushed out into the duodenum with a Fogarty balloon catheter. If the stone diameter was larger than 15 mm, then basket lithotripsy was performed before balloon dilation.

Results

Overall success rate was 95.7%. The procedure was successful in 97.5% of patients with CBD stones and in 61.5% of patients with hepatolithiasis. A total of 18 (6.8%) major complications, including cholangitis (n = 7), subcapsular biloma (n = 4), subcapsular hematoma (n = 1), subcapsular abscess (n = 1), bile peritonitis (n = 1), duodenal perforation (n = 1), CBD perforation (n = 1), gastroduodenal artery pseudoaneurysm (n = 1), and right hepatic artery transection (n = 1), were seen after the procedure. There was no mortality.

Conclusion

Our experience suggests that percutaneous transhepatic stone expulsion into the duodenum through the papilla is an effective and safe approach in the nonoperative management of the bile duct stones. It is a feasible alternative to surgery when endoscopic extraction fails or is rejected by the patient.     

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.     

Fish Bone as a Nidus for Stone Formation in the Common Bile Duct: Report of Two Cases

We report two cases of common bile duct stone formed around a fish bone which migrated from the intestinal tract, along with their characteristic imaging findings. Two patients who had no history of previous operation were admitted because of cholangitis. Percutaneous transhepatic biliary drainage (PTBD) was performed and the cholangiogram showed filling defects with an unusually elongated shape in the common bile duct. After improvement of the cholangitic symptoms, the stones were removed through the PTBD tract under fluoroscopic guidance. A nidus consisting of a 1.5 cm sized fish bone was found in each stone removed.     

经皮经肝取石术治疗胆总管结石25例

目的 探讨经皮经肝胆结石取出术治疗胆总管结石的临床应用价值.方法 自2013年1月至2015年1月,25例胆总管结石患者采用经皮经肝途径取石.首先在超声或者X线透视引导下完成PTC并放置8F鞘;然后采用8～12 mm球囊扩张乳头,如结石直径超12 mm,加用网篮碎石;最后采用取石球囊通过交换导丝将结石经十二指肠乳头括约肌推至肠道内.结果 25例患者包括胃肠道术后(18例)、内镜治疗失败(3例)、不愿意接受内镜治疗(3例)、其他情况(1例).25例患者均成功取出结石.术后3例(12％)发生并发症,分别为发热2例、肝脓肿形成1例,随访6个月到3年,2例患者因原患肿瘤复发转移死亡,1例患者胆总管结石复发,无反流性胆管炎发生.结论 经皮经肝胆结石取出术治疗胆总管结石具有较高的手术成功率以及较低的并发症发生率,可以作为不适合内镜治疗或者内镜治疗失败的胆总管结石患者的治疗措施.     

The value of extracorporeal shock-wave lithotripsy in the management of bile duct stones

We evaluated the role of biliary extracorporeal shock-wave lithotripsy in treating 70 symptomatic patients with bile duct stones in whom endoscopic or percutaneous radiologic attempts at basket extraction had failed. Forty-four patients had common bile and/or common hepatic duct stones, 21 patients had cystic duct stones, and five patients had intrahepatic duct stones. A total of 43 patients (61%) had complete elimination of stone fragments during the initial treatment period. If patients in whom stones were successfully fragmented yet not totally eliminated on initial hospital treatment but who were asymptomatic at follow-up times of 8-22 months are included, the overall successful treatment rate was 83%. Stones were cleared in 26 of 44 common bile/hepatic duct stone patients, spontaneously in seven patients and after endoscopic or percutaneous radiologic intervention in 19 patients. Fifteen (71%) of 21 patients had cystic duct stones successfully cleared. The fragments in two of five patients with intrahepatic duct stones also were cleared. Five patients (7%) had minor side effects. Seven (10%) of 70 patients went on to have surgery. Complications after 30 days occurred in five patients (7%); two required repeated endoscopy with fragment extraction, two required placement of an endoprosthesis, and one died. We conclude that biliary extracorporeal shock-wave lithotripsy is valuable as an adjuvant to standard interventional techniques for removing bile duct stones.     

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 management of bile duct stones

This article presents a review of the interventional radiological procedures in the percutaneous management of the bile duct stones through T-tube or transhepatic tracts. Interventional stone removal techniques mainly include extraction through the T-tube tract with baskets or forceps and expulsion into the duodenum by means of baskets or balloon catheters with the dilatation of the sphincter of Oddi. Fragmentation or size reduction of the stone, dilatation of the strictures and cholangioscopic assistance can facilitate the procedures.     

Monooctanoin infusion and stone removal through the transparenchymal tract: use in 17 patients

Seventeen patients underwent monooctanoin infusion and biliary stone removal through the percutaneous transhepatic biliary drainage tract. In the first five patients, monooctanoin was infused until the stone(s) became smaller or disappeared; basket extraction was not attempted until this reduction was observed. An average of 22 hospital days was required for the procedure. In the next 12 patients, basket extraction was attempted after as few as 3 days of infusion, without waiting for a reduction in stone size. After infusion, these stones became extremely friable, fragmented easily, and were atraumatically removed through the fresh liver tract. The average hospital stay for these patients was 7 days, with no complications. The ability of monooctanoin to soften some stones allows an earlier, more aggressive approach to stone removal through the transparenchymal tract without risk of soft-tissue laceration; use of the infusion significantly decreases the hospital stay.     

Percutaneous removal of retained intrahepatic stones utilizing combination of techniques with emphasis on a preshaped angulated catheter: review of 170 patients

Intrahepatic stones are frequently associated with recurrent cholangiohepatitis and complete surgical removal of the stones is almost always difficult because of the large number of stones and the associated bile duct strictures. One hundred and seventy patients with retained intrahepatic stones underwent percutaneous stone removal utilizing pre-shaped angulated catheters, 9-F polyethylene tubes with different angles of distal tip, and Dormia baskets under fluoroscopy with a combination of techniques including irrigation-suction, crushing of large stones, balloon dilatation of strictures and extracorporenal shock wave lithotripsy. The procedure was performed through a mature T-tube tract (168 patients) and a mature transhepatic tube tract (two patients). Stones were exclusively intrahepatic in 125 patients, whereas 45 patients also had stones in the common bile duct.In 84 (49.4%) of 170 patients, the stones were completely removed and in 36 (21.2%) patients, most of the stones were removed. Overall success rate was 70.6%. Angulation deformity, stricture of bile ducts and impacted stones were the factor mosto ften responsible for failure. No significant complications were observed.Fluoroscopically-guided percutaneous interventional procedures with a pre-shaped angulated catheter is a useful complementary procedure to surgery for patients with intrahepatic stones. The major benefits of an individually fitted angulated catheter are its safety and easy access to small peripheral bile ducts.     

Therapeutic applications of catheter cholangiography

Percutaneous transhepatic catheterization of the biliary tree was performed in 23 patients. In 21 the catheter was advanced past an obstructing lesion into the distal common bile duct and duodenum to establish antegrade biliary drainage. The catheter was left permanently in place as a form of endoprosthesis in 5 patients.     

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.     

Choledocholithiasis: treatment with extracorporeal shock wave lithotripsy

In a patient with choledocholithiasis, a duodenal diverticulum precluded endoscopic retrograde bile duct cannulation. A transhepatic catheter was used to opacify the bile ducts and to guide the endoscopic sphincterotome into the major duodenal papilla. Because limited sphincterotomy did not allow extraction or spontaneous passage of the common duct stones, extracorporeal lithotripsy was performed. Following fragmentation, the stones passed spontaneously and without complications.     

Transhepatic balloon dilation of the distal common bile duct and ampulla of Vater for removal of calculi

In 17 patients with common bile duct calculi, percutaneous transhepatic balloon dilation of the distal common bile duct and the ampulla of Vater (hepaticopancreatic ampulla) was performed. The calculi were pushed into the duodenum with the catheter, and all were removed without significant complications. This method of calculus removal is an effective alternative to surgery or endoscopic sphincterotomy.     

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.