V11-03: Applying Urolithiasis Techniques to Biliary Stones: Percutaneous Transhepatic Lithotripsy
Choledocolithiasis is a significant problem that can lead to severe cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is firstline treatment. However, this is not always possible when the patient has surgically altered anatomy or very large stone burden. Urologists can use our skills and technology to assist in these situations. We report our technique and outcomes from our 15 years of experience with percutaneous transhepatic endoscopic biliary lithotripsy.
Patients are selected by our gastroenterology colleagues who approach us for assistance when ERCP is not possible. We utilize a percutaneous transhepatic endoscopic approach in a combined procedure with interventional radiology. Most patient have a transhepatic biliary drain already in place. A wire is then placed through the tube into the biliary system and into the common bile duct. A 14-French ureteral access sheath is placed under fluoroscopic guidance into the common bile duct. A flexible ureteroscope is then guided through the access sheath into the biliary system. A holmium laser is used to fragment the stones. The stones can be subsequently retrieved or flushed into the intestinal tract.
Over the 16-year time period, a total of 26 procedures were performed on 18 patients (mean age 55.8 years). The indications were surgically altered anatomy in the majority of the cases that did not allow access via ERCP. Two of the patients had a large biliary stone burden which was too large to be managed by ERCP. Stone clearance was achieved in 16 of the 18 (89%) patients after a mean of 1.1 procedures. Most of these patients (61%) required only one procedure to become stone free. There were no Clavian grade III or higher complications. One patient developed cholangitis that resolved with administration of intravenous fluids and antibiotics. There were no instances of injury to the biliary system, pancreatitis, or need for urgent re-intervention at our institution.
With a multidisciplinary approach and the correctly selected patient, percutaneous transhepatic biliary endoscopic lithotripsy is a safe and effective intervention for complex biliary stones. Endourologic urolithiasis techniques can play a role in the treatment of patients with choledocolithiasis not amenable to ERCP. This improves patient care by decreasing the need for invasive surgery when ERCP is ineffective.