Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Apr 16, 2019; 11(4): 298-307
Published online Apr 16, 2019. doi: 10.4253/wjge.v11.i4.298
Percutaneous transhepatic cholangioscopy and lithotripsy in treating difficult biliary ductal stones: Two case reports
Edward Alabraba, Simon Travis, Ian Beckingham
Edward Alabraba, Ian Beckingham, Department of Hepato-Pancreato-Biliary Surgery, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
Simon Travis, Department of Radiology, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
Author contributions: All authors contributed to this paper.
Informed consent statement: Informed consent was obtained from the patient.
Conflict-of-interest statement: Drs. Alabraba, Travis and Beckingham have no conflicts of interest or financial ties to disclose.
CARE Checklist (2016) statement: Information for writing case report has been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Edward Alabraba, FRCS, Surgeon, Consultant HPB Surgeon, Department of Hepato-Pancreato-Biliary Surgery, Queen’s Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom. edwardal@liv.ac.uk
Telephone: +44-115-9249924 Fax: +44-115-8493398
Received: February 20, 2019
Peer-review started: February 20, 2019
First decision: February 26, 2019
Revised: March 15, 2019
Accepted: March 26, 2019
Article in press: March 26, 2019
Published online: April 16, 2019
Processing time: 57 Days and 4.4 Hours
Abstract
BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.

CASE SUMMARY

We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.

CONCLUSION

PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.

Keywords: Percutaneous transhepatic cholangiography; Video cholangioscopy; Lithotripsy; Biliary calculi; Endoscopic retrograde cholangiopancreatography; Case report; Bilio-enteric anastomotic strictures

Core tip: The purpose of this case report is to highlight the feasibility of percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) as therapy for biliary obstruction in patients with surgically altered anatomy which makes them unsuitable for conventional endoscopic retrograde cholangiopancreatography. Percutaneous transhepatic cholangiography used for emergency biliary drainage provides the access required for PTCSL, so it is reasonable to consider PTCSL in such patients. PTCSL attractively combines radiological and endoscopic techniques already established in most Hepato-Pancreato-Biliary units. Advanced endoscopic options are not widely available, and surgical options are limited as such patients are poor surgical candidates. We review the literature to compare our cases to previously reported cases of PTCSL.