Percutaneous transhepatic lithotripsy with the holmium: YAG laser for the treatment of refractory biliary lithiasis. Surg Laparosc Endosc Percutan Tech. 2009;19:106-109. [PMID: 19390274 DOI: 10.1097/sle.0b013e31819fa5d5]

Safety, efficacy, and feasibility of percutaneous transhepatic endoscopic holmium laser lithotripsy for bile duct stones

OBJECTIVE

To evaluate the safety and efficacy of percutaneous transhepatic endoscopic holmium laser lithotripsy (PTEHL) for patients with intrahepatic bile duct (IHBD) and common bile duct (CBD) stones.

MATERIAL AND METHODS

This retrospective study included 530 patients (mean age: 55.6 ± 8.5; 64.2% female) with IHBD and/or CBD stones at a single institution from January 2019 to December 2021. PTEHL was the chosen treatment for patients with large, complex stones, or those for whom Endoscopic Retrograde Cholangiopancreatography (ERCP) failed or presented difficulties. Patients showing signs of cholangitis required pre-PTEHL drainage. Stone clearance was confirmed by post-procedural cholangiography, and the technique was deemed successful when target stones were removed. Complications were recorded according to the Society of Interventional Radiology adverse event classification.

RESULTS

The mean stone size was 20.9 ± 11.9 mm, multiple stones observed in 460 patients (86.8%). A total of 225 patients (42.5%) had stones in both the IHBD and CBD; biliary-enteric anastomosis in 50 patients (9.4%). ERCP for stone removal proved unsuccessful in 18 patients (3.4%). Pre-IHBD drainage was performed in 271 patients (51.1%). The majority (488 patients, 92.1%) underwent a single PTEHL session. The technique was successful in 523 patients (98.7%), with 7 patients requiring surgery due to unsuccessful target stone removal. Complications were noted in 75 patients (14.2%), including 4.7% with severe complications and 9.4% with minor complications.

CONCLUSION

PTEHL is a safe and effective method for the treatment of both intrahepatic and extrahepatic bile duct stones. This approach is a valuable option for complex stone cases, particularly when ERCP is unsuccessful or encounters significant challenges.

CLINICAL RELEVANCE STATEMENT

Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy is a safe and effective treatment method for intrahepatic and extrahepatic biliary stones, particularly in cases of complex stones.

KEY POINTS

Percutaneous transhepatic biliary stone removal is difficult for large or intraductal stones. Percutaneous Transhepatic Endoscopic Holmium Laser Lithotripsy (PTEHL) demonstrated a high success rate with few major complications. PTEHL can treat biliary stones, particularly stones that are difficult or have failed ERCP treatment.

Bouveret syndrome masquerading as a gastric mass-unmasked with endoscopic luminal laser lithotripsy: A case report

BACKGROUND

Bouveret syndrome, also known as gallstone ileus, is a rare form of gastric outlet obstruction accounting for 1%-3% of cases. This condition is most often reported in females. The diagnosis can be challenging and is often missed due to atypical presentations, which occasionally mimic gastric outlet obstruction symptoms such as nausea, vomiting, loss of appetite and hematemesis. The symptoms vary with stone size. Larger stones are managed with a surgical approach, but this carries increased morbidity and mortality. Over the past decade, the endoscopic approach has emerged as an alternative mode of treatment, but it is generally unsuccessful in the management of larger-sized stones. A literature review revealed cases of successful endoscopic treatment requiring multiple sessions for stone sizes measuring up to about 4.5 cm. Here we present a unique case of an elderly patient with Bouveret syndrome with a 5 cm stone mimicking a gastric mass and causing gastric outlet obstruction, who was successfully managed in a single session using a complete endoscopic approach with laser lithotripsy.

CASE SUMMARY

An 85-year-old female patient presented with 1-month history of intermittent abdominal pain, vomiting, decreased appetite and weight loss. An abdominal computed tomography showed a 4.5 cm × 4.7 cm partially calcified mass at the gastric pylorus causing gastric outlet obstruction. Endoscopy showed an ulcerated fistulous opening and a large 5 cm impacted gallstone in the duodenal bulb. Endoscopic nets and baskets were used in an attempt to remove the stone, but this approach was unsuccessful. Given her advanced age, poor physical condition and underlying comorbidities, she was deemed to be high-risk for surgery. Thus, a minimally invasive approach using endoscopic laser lithotripsy was attempted and successfully treated the stone. Post-procedure, the patient experienced complete resolution of her symptoms with no complications and was able to tolerate her diet. She was subsequently discharged home at 48 h, with an uneventful recovery.

CONCLUSION

In our paper we describe Bouveret syndrome and highlight its management with a novel endoscopic approach of laser lithotripsy in addition to various other endoscopic approaches available to date and its success rates.

Cholecystostomy as an Exclusive Access to Remove Cystic, Common Hepatic, and Common Bile Duct Stones

OBJECTIVE. The purpose of this article was to evaluate the feasibility and efficacy of percutaneous fluoroscopic-guided stone retrieval from the cystic duct and antegrade common bile duct (CBD) stone advancement into the duodenum exclusively through a cholecystostomy tube. MATERIALS AND METHODS. Twenty-one patients with acute cholecystitis and choledocholithiasis or an impacted cystic duct stone who underwent percutaneous cholecystostomy tube placement were retrospectively enrolled in this study. The patients had a contra-indication for cholecystectomy (17 patients because of comorbidities and one who declined surgery) or had failed endoscopic retrograde stone removal attempts (three patients). RESULTS. The 21 patients underwent subsequent percutaneous CBD (17 patients) and cystic duct (nine patients) stone removal on follow-up sessions through the percutaneous cholecystostomy track using moderate sedation. A total of 32 stone removal procedures were performed. Seventeen patients underwent balloon dilatation sphincterotomy, after which the CBD stones were pushed forward into the duodenum using a compliant balloon. Seven patients also had stone removal from the cystic duct by a stone retrieval basket. The primary technical success rate for removal of all CBD and cystic duct stones was 76%. The secondary technical success rate was 100%. The clinical success rate was 74%. All patients tolerated the procedures well without major complication. The clinical follow-up interval ranged from 2 to 2310 days (median, 30 days), with no incidence of postprocedural complications. CONCLUSION. Percutaneous transcholecystic common bile and cystic duct stone removal through an existing cholecystostomy access is a safe and effective procedure that is well tolerated.

Ultra-mini Percutaneous Hepatolithotomy in Patients With Large and Multiple Hepatolithiasis

BACKGROUND

In this study, we applied the ultra-mini percutaneous hepatolithotomy (UM-PHL) technique on hepatolithiasis patients with multiple and large stones on which other minimally invasive methods failed, and our aim was to report its results, sharing in series for the first time.

MATERIALS AND METHODS

Preoperative and postoperative data, laboratory parameters, radiologic findings, and preoperative and postoperative details were recorded for a total of 14 patients for whom the UM-PHL technique was applied between April 2017 and December 2019. As all patients had multiple stones and extreme stone load and had bile duct surgery, they did not have a normal anatomy. All patients were radiologically confirmed to have had preprocedural magnetic retrograde cholangiopancreatography.

RESULTS

Operation duration of the patients was 137.6±44.9 minutes, while intraoperative blood loss was 69.2±24.9 mL, drainage catheter removal time was 2.85±0.86 days, and the hospitalization time was 4.28±2.55 days. Intraoperative balloon dilation was applied to enlarge the stricture area in 5 patients (35.7%). On the basis of the Clavien-Dindo classification, grade 2 complication was observed in 2 patients (14.2%) due to postoperative cholangitis. Patients were followed up for an average of 15 months, and nonsymptomatic radiologic stone recurrence was detected in the 12th month control of 1 patient (7.1%).

CONCLUSION

The UM-PHL technique is a successful method that facilitates stone clearance by providing minimal dilatation through percutaneous intervention and by using instruments with small diameter, and it can safely be applied with its low complication level, low recurrence ratio, and short hospitalization time.

Percutaneous transhepatic endoscopic lithotripsy of biliary stones with holmium laser for the treatment of recurrent cholangitis

PURPOSE

To evaluate the efficacy and safety of percutaneous transhepatic endoscopic holmium laser biliary lithotripsy (PTBL) to treat recurrent cholangitis due to intra/extrahepatic stones, in patients not candidate for traditional endoscopic treatment.

MATERIALS AND METHODS

We retrospectively evaluated 28 patients (M:F = 19:9, mean age = 65 years, SD = 14) undergoing 43 PTBL for stone-related recurrent cholangitis from January 1, 2012 to January 31, 2019 in a single academic center. Data collected included demographics, location and number of stones, clinical success after one (primary) or more than one (secondary) PTBL, procedure time, duration of hospital stay, number of retreatments and post-procedural complications. Clinical success was defined as the resolution of cholangitis at 30-day follow-up.

RESULTS

PTBL were successful for 23/28 (82%) patients, 16 (57%) with one and 7 (88%) with repeat procedures. The remaining 5 (18%) patients were finally treated with surgery (3, 11%) or further antibiotics (2, 7%). PTBL were performed to treat intrahepatic stones (22 treatments, 51%), extrahepatic (14, 33%), and both intra/extrahepatic (7, 16%). One to three stones were found in 12/43 (28%) PTBL, more than three in 31/43 (72%). Single PTBL was performed in 20/28 (71%) patients, two in 3/28 (11%), three in 3/28 (11%), and four in 2/28 (7%). Median procedure duration was 115 (29-210, 95% CI 101-129) minutes; median hospital stay was 5.5 (2-42) days. The only major complication was the breakage of a guidewire tip, surgically retrieved; minor complications included one aspiration pneumonia and three instances of intrahepatic hemorrhage, treated conservatively.

CONCLUSIONS

PTBL was clinically successful in the 82% of patients not candidate for endoscopic treatment, with a low complication rate.

Percutaneous transhepatic laser lithotripsy for intrahepatic cholelithiasis: A technical report

Advances in interventional radiology have seen the adaptation of urological endoscopic laser techniques to treat biliary tract calculi. Percutaneous transhepatic biliary laser lithotripsy provides an effective alternative procedure for the management of intrahepatic or conventionally refractory choledocholithiasis which would otherwise require invasive and high-risk surgical intervention. Several small studies have validated the procedure for management in this subset of patients, with most achieving 100% calculi clearance with minimal complications. Most patients are suitable for percutaneous transhepatic biliary laser lithotripsy. Preprocedural imaging is useful for evaluating stone burden and planning percutaneous access. Holmium lasers are commonly used and act by vaporising water particles on and in the calculi, fragmenting the stone via thermal expansion. A series of catheters, wires, sheaths and dilators are used to allow introduction of the choledochoscope and laser so that calculi can be targeted. Percutaneous transhepatic biliary laser lithotripsy is often used in conjunction with balloon dredging and biliary stricture dilatation. Only experienced interventionalists should perform this procedure, and users should be aware of associated hazards. Repeat percutaneous transhepatic cholangiography is routinely performed to confirm eradication of stones. Treatment of biliary calculi and obstruction is important in preventing diseases such as cholangitis and cirrhosis. For patients unsuitable for conventional treatment, percutaneous transhepatic laser lithotripsy is a safe and effective alternative when performed by experienced interventional radiologists. Preprocedural planning is imperative to procedure success.

Biliary and pancreatic lithotripsy devices

BACKGROUND AND AIMS

Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL).

METHODS

In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations.

RESULTS

Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs.

CONCLUSIONS

Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Holmium Intraductal Laser Lithotripsy of Biliary Stones in Liver Grafts

BACKGROUND

Biliary stones after liver transplantation (LT) rarely occur but a focus on those complications and their treatment is needed.

PATIENTS AND METHODS

In total, 390 adult patients who underwent an LT from July 2004 to July 2014 entered the study. Biliary complications and notably biliary stones after LT were identified.

RESULTS

In total, 365 LT were analyzed. Biliary stones were identified in 14 patients (3.8%). Predictive factors for the onset of biliary stones after LT were hepatocellular diseases (P = .038; OR = 9.7) and biliary stenosis (P = .000; OR = 11.9). Treatments consisted of percutaneous transhepatic procedures (4 patients), endoscopic retrograde procedures (9 patients), and in open surgery (1 case); in 2 cases, due to a failure of previous treatments, holmium intraductal laser lithotripsy (HILL) was used: the first patient, a 35-year-old woman developed multiple intrahepatic biliary stones after LT. Percutaneous transhepatic cholangiography (PTC) was ineffective and a HILL was performed, clearing the right common bile duct but leaving residual stones in the left duct. The patient underwent a retransplantation due to recurrent hepatitis C virus infection but died 3 months later because of graft failure. The second patient, a 42-year-old 14 years after retransplantation, developed biliary sludge and stones; after several attempts with PTC and endoscopic retrograde cholangiopancreatography, a HILL was performed. All stones except one big one were treated. The patient is alive and well.

CONCLUSIONS

When usual treatments are unsuccessful and biliary stones are large, their fragmentation and treatment could be done with HILL, a promising procedure after LT.

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

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.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones

PURPOSE OF THE STUDY

To report our experience in treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL).

PATIENTS AND METHODS

Ten symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Six of these patients had previously undergone unsuccessful endoscopic treatment; four patients were declared not suitable for endoscopic procedure. PTBL was performed with a flexible choledochoscopy inserted by way of the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary and an occlusion balloon for the clearance of common bile duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical follow up was performed by the referring physician. Technical success, clinical success and complications were evaluated.

MAIN FINDINGS

Technical success rate was 100%. The overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6-25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the patients.

CONCLUSIONS

Complicated or large biliary calculi can be treated successfully using PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.

Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones

PURPOSE

To report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL).

PATIENTS AND METHODS

Twenty-two symptomatic patients (11 men and 11 women, age range 51 to 88 years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-μm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure.

RESULTS

All stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (n = 3), for choledochalenteric anastomosis (n = 3), and for recurrent cholangitis (n = 1). Adjunctive "balloon push" (n = 4) and "rendezvous" (n = 1) procedures were needed to completely clean the biliary tree. None of these patients needed surgery.

CONCLUSION

Complicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.