2164 Percutaneous Transhepatic Single-Operator Cholangioscopy With Electrohydraulic Lithotripsy in the Management of Intrahepatic Stones in a Post-Orthotopic Liver Transplant Patient With Ischemic Cholangiopathy

Abstract

INTRODUCTION: Advancements in endoscopic retrograde cholangiopancreatography (ERCP) have revolutionized the management of biliary stones. However, endoscopic management of intrahepatic stones continues to be challenging. We discuss a patient with intrahepatic stones who was treated with percutaneous transhepatic cholangioscopy with electrohydraulic lithotripsy (EHL). CASE DESCRIPTION/METHODS: A 68-year-old man with alcoholic cirrhosis underwent orthotopic liver transplant from a deceased after cardiac death donor. His post-transplant course was complicated by ischemic cholangiopathy, biloma development and recurrent episodes of cholangitis. He underwent placement of an external biliary drain for management of his biloma. An MRCP demonstrated persistent biloma as well as mural irregularities within the intrahepatic ducts concerning for intrahepatic stones. Due to recurrent cholangitis, a combined IR (interventional radiology)-biliary endoscopic procedure was undertaken. IR performed a percutaneous cholangiogram (PTC) which demonstrated multiple filling defects in the left hepatic ducts consistent with stones. A 5 French Fogarty balloon was advanced and inflated with multiple sweeps in an attempt to extract the filling defects into the common bile duct. Antegrade cholangioscopy was then performed with single-operator cholangioscope (SpyGlass 2™) passed through a 14 French PTC sheath. Using the cholangioscope we were able to visualize impacted stones within the left intrahepatic system and treat them utilizing EHL with a catheter setting of 40-50 Watts for stone fragmentation and suction. The single-operator cholangioscope was then directed at the common bile duct and two large retained stones were treated with EHL. Subsequently, a traditional ERCP was performed which noted filling defects within the common bile duct. Balloon sphincteroplasty was performed and using an 8.5-11.5 mm balloon catheter, CBD exploration and balloon sweeps were performed with extraction of 2 large stones and sludge. Occlusion cholangiogram at the completion of the procedure revealed no further stones and patent anastomosis. To allow adequate biliary drainage, a retrievable 10 mm × 60 mm SEMS covered metal biliary stent and a new 14 French external biliary drain was placed. The biliary stent was removed 3 months later with ERCP demonstrating no recurrent stones. DISCUSSION: Complex intrahepatic lithiasis may be successfully managed with a multi-disciplinary collaborative approach between Interventional Radiology and biliary endoscopists.