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

Abstract

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.

Keywords: Cholangiolithiasis; Cholangioscopy; Laser; Lithotripsy; Liver transplant.

Fig. 1

CT abdomen and pelvic on the day of presentation. Axial (A and B), coronal (C), and sagittal (D) views. Extensive hyperdensities (white arrows) within tubular structures on this noncontrast CT in this post liver transplant and recent postliver biopsy may represent; blood in the bile duct, biliary calculi or possibly venous thrombosis.

Fig. 2

MRI of abdomen 1 day after presentation. Axial (A and B), coronal (C), and MRCP (D) views. Liver transplant is noted in the right upper quadrant. There is marked intrahepatic biliary dilatation, with multiple intraluminal gallstones (white arrows) including a 1-cm stone at the right main duct and near complete occlusion of the right posterior biliary duct.

Fig. 3

Preliminary cholangiogram and biliary drainage catheter placement 5 days after presentation. (A) and (B). Frontal and right anterior oblique views showed diffuse dilatation of the opacified right biliary ducts with numerous filling defects (white arrows) concordant with biliary stones. (C) Placement of a right-sided 8 French external biliary drainage catheter (black arrow) via subcostal midaxillary approach with the loop formed near the confluence of the right hepatic ducts.

Fig. 4

Follow-up over-the-wire cholangiogram 12 days after initial cholangiogram. (A) Cholangiogram revealed numerous filling defects representing intraductal stones (white arrows) in the right intrahepatic biliary system. (B) There was a large common bile duct stone at the stenotic hepaticojejunostomy anastomosis (black arrow). (C) An 8-mm Mustang Balloon (white arrow head) was used in to sweep stones from the central ducts antegrade into the jejunum. Balloon dilation of the hepaticojejunal anastomosis was performed with 10 mm and 12-mm balloons. (D) A new 12 French biliary drainage catheter was advanced over the wire into the biliary tree. The distal pigtail was formed in the duodenum (black arrow head).

Fig. 5

Cholangiogram approximately 5 weeks after presentation. (A) A 14 French sheath (white arrow) was positioned at the entry site to the accessed right biliary duct. Subsequently, a Wittich nitinol basket (black arrow) was applied to extract a large amount of stones from the accessed right biliary duct. (B) A 5.5 French Fogarty balloon (white arrow head) was used for sweeping of a large stone out of a more superior duct (black arrow head). (C) However, the stone (black arrow head) was too large to be retrieved with a basket or swept beyond the hepaticojejunostomy.

Fig. 6

Cholangioscopy 8 weeks after first presentation. (A-D) Eight weeks after the last cholangiogram, laser (black arrow) and mechanical lithotripsies were used under cholangioscopic guidance with Fogarty balloon to remove large hilar stone (white arrow) and other multiple stones.

Fig. 7

Cholangiogram approximately 3.5 months after presentation. (A) Cholangiogram showed persistent focal narrowing (white arrow) in the central segment of the right biliary duct. (B) Cholangiogram through the 12 French biliary drain showed no definite filling defects.

Fig. 8

MRI of abdomen 6 months after removal of biliary drains. Axial (A and B), coronal (C), and MRCP (D) views. Liver transplant is noted in the right upper quadrant. There is no intrahepatic biliary dilatation or intraluminal gallstones.