Biliary duct stones: percutaneous transhepatic removal

Percutaneous removal of biliary stones post-liver transplant in a pediatric patient: Case report and review of the literature

This case report describes an 8-year-old girl who underwent a segmental LT for a primary diagnosis of citrullinemia at the age of 12 months. She presented with cholangitis secondary to stenosis of the biliary-enteric anastomosis. MRI revealed dilatation of intrahepatic bile ducts associated with multiple stones. An endoscopic approach failed to decompress the bile ducts and remove the stones. A percutaneous approach was then undertaken. After placement of a temporary external biliary drain for 12 days, a 26 French sheath was placed to access the bile ducts. Using a 14Fr flexible cystoscope, 80%-90% of the biliary stones were removed. This was followed by antegrade balloon dilatation of the biliary-enteric anastomosis. Two months later, the procedure was repeated, resulting in complete clearance of the biliary stones. An internal-external biliary drain was maintained in placed for 10 months. The patient has been asymptomatic, with no evidence of stone recurrence for 13 months after drain removal. Percutaneous biliary stone removal is commonly performed in adults with non-transplanted livers, especially in complex cases, and has also been shown to be successful in the pediatric population. However, it is rarely reported in transplanted livers in adults, and to the best of our knowledge, no pediatric cases have been reported. This case illustrates that this technique can be successfully utilized in pediatric LT patients.

The Light at the End of the Tunnel

Approximately 5%–10% of common bile duct (CBD) stones cannot be removed by conventional methods because of altered anatomy. Percutaneous transhepatic cholangioscopic lithotomy has been cited as a viable alternative. A 69-year-old woman with a history of Roux-en-Y was found to have a lesion obstructing the CBD. A cholangioscope was advanced through a percutaneous transhepatic sheath and demonstrated an obstructing stone in the CBD that was removed with lithotripsy. The rate of successful stone removal with percutaneous transhepatic cholangioscopic lithotomy is 90%, with complication rates similar to endoscopic retrograde cholangiopancreatography and is an option in patients with altered surgical anatomy.

Percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract

Purpose

In the present study, the effectiveness and safety of minimally invasive percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract were assessed.

Material and methods

Between 2000 and 2015, 12 patients (seven women and five men, mean age 78 ± 8 years) after open cholecystectomy with common bile duct exploration and T-tube drainage underwent percutaneous extraction of residual gallstones through the T-tube tract.

Results

The intervention was successful in 92% (11/12). In seven patients complete extraction of the retained gallstones was achieved, and in four cases partial extraction combined with passage of small residual fragments to the duodenum was obtained. In one case the extraction attempt was ineffective. Mild haemobilia was observed in two patients. No mortality or major complications were observed.

Conclusions

Our findings are consistent with literature data and confirm that percutaneous extraction of residual post-cholecystectomy gallstones through the T-tube tract is an effective and safe treatment method. Although the presented technique is not a novel approach, it can be beneficial in patients unsuitable for open surgery or laparoscopic intervention when ERCP attempt occurs ineffective or there exist contraindications to ERCP.

Percutaneous Biliary Interventions

Biliary drainage is important in the care of patients with benign and malignant biliary obstruction. Careful preprocedure evaluation of high-quality cross-sectional imaging and inventory of symptoms are necessary to determine whether a percutaneous, endoscopic, or surgical approach is most appropriate. High bile duct obstruction is usually best managed percutaneously; a specific duct can be targeted and enteric contamination of isolated ducts can be avoided. Options for percutaneous biliary intervention include external or internal/external biliary drainage, stent placement, biliary stone retrieval, and bile duct biopsy. Preprocedure evaluation, technique, and indications for percutaneous intervention in benign and malignant diseases are summarized.

Overview of Emerging Contaminants and Associated Human Health Effects

In recent decades, because of significant progress in the analysis and detection of trace pollutants, emerging contaminants have been discovered and quantified in living beings and diverse environmental substances; however, the adverse effects of environmental exposure on the general population are largely unknown. This review summarizes the conclusions of the comprehensive epidemic literature and representative case reports relevant to emerging contaminants and the human body to address concerns about potential harmful health effects in the general population. The most prevalent emerging contaminants include perfluorinated compounds, water disinfection byproducts, gasoline additives, manufactured nanomaterials, human and veterinary pharmaceuticals, and UV-filters. Rare but statistically meaningful connections have been reported for a number of contaminants and cancer and reproductive risks. Because of contradictions in the outcomes of some investigations and the limited number of articles, no significant conclusions regarding the relationship between adverse effects on humans and extents of exposure can be drawn at this time. Here, we report that the current evidence is not conclusive and comprehensive and suggest prospective cohort studies in the future to evaluate the associations between human health outcomes and emerging environmental contaminants.

Usefulness of percutaneous transhepatic cholangioscopic lithotomy for removal of difficult common bile duct stones

Background/Aims

Approximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones.

Methods

This study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL.

Results

Among 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality.

Conclusions

Despite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

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.

Late biliary complications in pediatric liver transplantation

PURPOSE

The aim of this study was to review the biliary complications occurring in late follow-up after liver transplantation in children.

METHODS

The medical records of 135 children who received orthotopic liver transplantations (OLT) and had graft survival of more than 1 year were reviewed. Technical variants using a reduced-size graft were applied in 32 (23.7%). For biliary reconstruction, 15 patients had choledochocholedochostomy and 120 a Roux-en-Y loop. Biliary reoperation in the early post-OLT period was needed in 24 patients (17.7%). Routine checking of liver function and duplex Doppler ultrasonography (DDS) were performed during the follow-up period, which averaged 58 months. Late biliary complication was defined as that occurring after the first hospital discharge.

RESULTS

Late biliary complications occurred in 18 children (13.3%); 16 showed symptoms or analytical disturbances in liver function tests. The Diagnoses included uncomplicated cholangitis (n = 6), anastomotic biliary stricture (n = 7), ischaemic damage of the biliary tree (n = 3) including one late (28 months) hepatic artery thrombosis leading to an intrahepatic biloma. and bile leak after T-tube removal (n = 2). The six children with uncomplicated cholangitis had no repeat episodes in follow-up despite persistent aerobilia. Six patients affected by anastomotic strictures were treated successfully with percutaneous dilatation and, if present, stone removal. Persisting dysfunction and cholangitis occurred in one case affected by ischaemic biliary disease. Biliary leaks after T tube removal settled spontaneously. Risk factors for late biliary complications were determined. There was no relation to the cold ischaemia time, type of graft or biliary reconstruction, or previous early post-OLT biliary reoperation. Aerobilia (affecting 21.5% of OLT patients) was related to cholangitis (P = .001).

CONCLUSIONS

Anastomotic strictures, reflux of intestinal contents via the Roux-en-Y loop, and residual ischaemic damage led to late biliary complications in 12% of paediatric OLT patients. Evidence of biliary dilatation on DDS may be delayed in anastomotic strictures; in these cases the results of percutaneous treatment were excellent. Children with aerobilia have and increased risk of cholangitis.

Choledocholithiasis associated with malignant biliary obstruction--significance and management

Distal bile duct stones and proximal extra-hepatic malignant biliary obstructions may coexist. These stones, probably predating the development of the malignant obstruction but of unknown aetiological significance, were found in seven of 60 patients with proximal tumours (11.6%) at percutaneous biliary drainage. In two of these cases, stones blocked outflow from a supra-ampullary stent. All seven patients also had evidence of gall-bladder stones. Five of the seven patients had cholangiocarcinoma, giving an incidence of duct stones in such patients (n = 27) of 18.5%. In one case, the stones were removed endoscopically, in four, the stones were removed percutaneously and, in the remaining two cases, they were left in situ beside a stent. None of 120 cases with malignant obstruction had stones proximal to the obstruction. Distal common duct stones are associated with proximal malignant biliary duct obstruction, especially with cholangiocarcinoma and coexisting gall-bladder stones. They may interfere with stent function and cause diagnostic confusion at cholangiography.

Surgical interventions for bile duct stones

Based on our experience of 420 common bile duct procedures for stone disease and a literature review, it is evident that treatment of common duct stones today is based on a wide variety of non-operative and surgical methods which are still being developed. The mode of treatment is basically related to the time of diagnosis. Methods also differ depending on the localization of calculi, on inflammatory complications of stone disease, and whether combined or isolated cholecystocholedocholithiasis is present. At the moment, traditional operative methods as well as newly developed advanced techniques have to be evaluated. Selection of patients and their appropriate surgical and non-surgical treatment is an important issue to be further developed in the next few years. Therefore, therapeutic indications and definitive therapy present a much more demanding challenge for the surgeon than in the period when only open surgery was available.

The management of problematic biliary calculi

Recent advances in modern medical technology have significantly reduced the number of patients with 'problematic calculi'. When a patient does present with a difficult bile duct stone, various non-surgical treatment options are now available. In experienced hands, with healthy or high-risk patients, percutaneous treatment is as safe and as efficacious as endoscopy or surgery. Since it does not require general anaesthesia, and patients recover much more quickly than after surgery, the percutaneous approach is preferred when endoscopy fails to achieve ductal clearance. Surgery is indicated for patients with lesions requiring surgical removal or correction, but seldom for removal of biliary calculi alone.