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

Abstract

Objectives: Clinical evidence regarding radiological-endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological-endoscopic management of intrahepatic difficult bile duct stones.

Methods: From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3-7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological-endoscopic approach and reported our technical and clinical outcomes.

Results: Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention.

Conclusion: After 18 years of experience we demonstrated that our combined radiological-endoscopic approach to 'difficult bile duct stones' may result in both immediate and long-term clearance of stones with a low rate of adverse events.

Keywords: bile ducts; biliary stones; cholangiography; endoscopy; lithotripsy.

Figure 1.

A 73 year-old man with previous history of recurrent biliary lithiasis and pancreatitis underwent cholecystectomy and gastric-jejunal anastomosis with side-to-side choledochojejunostomy. He presented to our institution with recurrent cholangitis and ultrasound diagnosis of biliary stones in the common bile duct (CBD) (‘sump syndrome’). (a) Magnetic resonance (MR) cholangiography shows dilated CBD and intrahepatic ducts with the presence of multiple stones (arrowheads). (b) Computed tomography (CT) confirmed the MR findings: note the better visualization of the lateral choledochojejunal anastomosis (black arrow). (c) Using a right transhepatic approach (through a bile duct of the V segment) a 10 Fr biliary drainage was inserted. Cholangiography showed multiple bile stones (arrowheads) and the presence of a plastic prosthesis within the CBD (arrows). (d) After 3 days the first cholangioscopy was performed, introducing the large cholangioscope into a 16 Fr introducer sheath, by using electrohydraulic lithotripsy probes (arrowhead). Also the ampulla was dilated with a 9 mm balloon (e) and stones were pushed down with a basket-type catheter (arrow, f) after removing the plastic stent. (g) After three more sessions, final cholangiography showed optimal result: no stenosis and no stones were present in the biliary system.

Figure 2.

A 64 year-old man with positive history for primitive sclerosant cholangitis, portal thrombosis and cholecystectomy presented with ascites, recurrent cholangitis and intrahepatic lithiasis. (a) Magnetic resonance (MR) T2w IR in coronal view shows bilateral stenosis of the bile ducts with presence of biliary stones in the right bile duct (arrows) and in the CBD (arrowhead) (Tsunoda class IV). Moreover abundant ascites is present around the liver. (b) A left transhepatic approach through the bile duct of the III segment was performed and a biliary drainage was placed. Cholangiography confirmed the MR findings: intrahepatic lithiasis (arrow) and lithiasis in the CBD (arrowhead). (c,d) Cholangioscopy was performed using a 11 Fr introducer with the small cholangioscope (size 2.7 mm) and also using a basket-type catheter. (e) After 3 days, cholangiography shows the optimal result without any sign of residual biliary stones.

Figure 3.

Flow diagram representing our management of patients with difficult bile duct stones. Bil, biliary; CT, computed tomography; EHL, electrohydraulic lithotripsy; ERCP, endoscopic retrograde cholangiopancreatography; Interv, intervention; MRCP, magnetic resonance cholangiopancreatography; PTC, percutaneous transhepatic cholangiography; pts, patients; US, ultrasound.

Figure 4.

Flow diagram showing our technical approach to the treatment of difficult bile duct stones. CS, cholangioscope; EHL, electrohydraulic lithotripsy; IR, interventional radiology; PTCS, percutaneous transhepatic cholangioscopy.

Figure 5.

Recurrence rates of hepatolithiasis during the follow up (months).