BERKELEY, CA (UroToday.com) - Patients with prior surgical alteration of the GI tract presenting with choledocholithiasis frequently fail standard methods of stone removal such as endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTHC) due to restricted access to the biliary system. Our findings suggest refractory stones in this subset of patients are amenable to treatment with intracorporeal lithotripsy via a percutaneous or peroral approach with a low rate of serious complications.
SURGICAL TECHNIQUE
Eleven of the 13 initial cases were performed percutaneously through a previously established PTHC tract, and 2 utilized a “mother-baby” endoscopic system via collaboration with a gastroenterologist. Appropriate antibiotics were administered preoperatively. EHL was utilized in 8 cases, and ILL was used in 5. From 2006 forward the holmium laser was used as it ultimately replaced EHL as the primary urologic lithotripter at our institution. Percutaneous procedures required general anesthesia, and peroral procedures were performed under conscious sedation.
Percutaneous Approach
All patients undergoing percutaneous approach had an existing percutaneous hepatic drain. Using standard techniques, the tract was dilated to 10-14F, with placement of an access sheath. The 7F flexible ureteroscope was advanced to the stone(s). Fragmentation was achieved using EHL at 10-50% power with mild irrigation, or 200/270 micron holmium laser fiber at 8Hz and 0.8 J. Stone fragments were flushed antegrade into the duodenum, or retrograde out of the access sheath. A cholangiogram was performed at the conclusion of the procedure to evaluate stone clearance, and when necessary, Fogarty balloon sweeps were used to clear residual stone fragments. The percutaneous hepatic drain was then replaced, and cholangiograms were performed between 2-20 days post-op to re-evaluate stone clearance.
Peroral Approach
In the 2 patients who had not undergone previous PTHC, collaboration with a GI endoscopist utilizing a “mother-baby” system was used to obtain access to the biliary system. Both cases were performed prior to 2006, so a 1.7F EHL probe was directed through the mother endoscope to the location of the stone, and fragmentation was accomplished using the aforementioned power settings. Basket and balloon sweeps were then performed by the endoscopist to clear any remaining fragments.
RESULTS
Stone location was equally distributed between the common bile duct (7/13) and intrahepatic tract (7/13), with one patient having stones in both locations. In regard to stone clearance, 93% (12/13) were rendered stone free after 1.33 ± 0.47 procedures, with 62% stone free after a single procedure. Follow up of 3-138 months (median: 99 months) revealed no patients with de novo strictures post lithotripsy. Major complication rate was low (1/20, 5%), as one patient experienced post-operative cholangitis and hypotension after a follow-up transhepatic EHL that resolved with 24 hours of ICU care with intravenous fluids and antibiotics. Two patients experienced low-grade fever after their initial successful procedure, but each resolved within 24 hours without additional management. Of the 20 total procedures performed, no cases of post-operative pancreatitis were observed.
COMMENT
To our knowledge, this is the first series to specifically assess treatment of biliary stones in patients with surgically altered GI anatomy. The interdisciplinary approach with interventional radiologists, gastroenterologists, and urologists provides a unique opportunity for minimally invasive intervention with decreased morbidity versus a standard open operation. Ultimately, the goal is stone clearance and symptomatic relief, with avoidance of long-term requirement for a percutaneous biliary catheter.
The limitations of our series include its retrospective nature, the transition of EHL to ILL over the course of the study, uneven distribution between percutaneous versus peroral access, and the small number of patients. Though multiple surgical modalities are available for patients with altered anatomy and biliary stones, the advent of the flexible ureteroscope with a narrow diameter permits access to an intricate and complicated biliary tree and minimizes bleeding by use of a smaller access sheath. Management is dictated by access to the hepatobiliary tree, surgeon experience, and preoperative functional status of the patient. In this unique group of patients, intracorporeal lithotripsy utilizing endourologic techniques produces high stone-free rates with minimal complications. Although a staged secondary procedure may be required for large stone burdens, it is still an attractive alternative to open stone removal with high morbidity.
Written by:
Brian C. Sninsky, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
Department of Urology, University of Wisconsin School of Medicine and Public Health , Madison, WI USA
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