Application value of percutaneous sinus-tract cholangioscopy in the diagnosis and treatment of residual intra- and extra-hepatic bile duct stones: a report of 1 045 cases

Abstract

Objective To investigate the application value of percutaneous sinus-tract cholangioscopy in the diagnosis and treatment of residual intra- and extra-hepatic bile duct stones. Methods The retrospective cross-sectional study was conducted. The clinical data of 1 045 patients with intra- and extra- hepatic bile duct stones who underwent percutaneous sinus-tract cholangioscopy or stone extraction in the Second Affiliated Hospital of Zhejiang University from January 2003 to June 2016 were collected. Patients received percutaneous sinus-tract cholangioscopy or stone extraction at 6-8 weeks after T tube drainage. Observation indicators: (1) diagnosis and stone extraction situstions: cases with residual stones, stone extraction frequency and clearance rate; the critics of clearance rate are no residual stone during operation combined with B ultrasound or T-tube cholangiography; (2) postoperative complications: incidence and management of postoperative complications, prognosis and Clavien-Dindo classification for postoperative complication; (3) follow-up situation. T-tube was removed when there was no residual stone. Patients were followed up by outpatient examination up to April 2017. B ultrasound reexamination was performed to detect the recurrence of stone once every 3-6 months. Results (1) Diagnosis and stone extraction situstions: among 1 045 patients, results of cholangioscopy showed 147 wihout bile duct stones and 898 with bile duct stones.Of 898 patients, 2 618 times cholangioscopic explorations for stone extraction were performed, with a maximum frequency of 16 times, and 851 had stones clearance, with a overall clearance rate of 94.77%(851/898). The clearance rates of extra- and intra- hepatic bile duct stones were 100.00%(221/221) and 93.06%(630/677). Of 47 patients with residual stones, 16 didn′t receive cholangioscopy due to branches stricture or occlusion of intrahepatic duct, 13 failed to take out stone due to T-tube dislodgement (9 cases) and improper placement (4 cases) induced closed T-tube sinus tract, 7 had T-tube sinus tract duodenal fistula, 6 gave up stone extraction, 3 was due to longer sinus tract induced bending and 2 was due to T-tube sinus tract fracture. (2) Postoperative complications: among 1 045 patients, 297 had level Ⅰ-Ⅱ mild complications and 13 had level Ⅲ and above severe complications. The common complications included fever, vomiting, diarrhea and so on; the special complications included T-tube sinus tract duodenal fistula of 13 patients, T-tube sinus tract fracture of 4 patients, rupture of broken stones pole of 3 patients, massive hemobilia of 2 patients, acute pancreatitis of 2 patients and cardiac arrest of 1 patient. The above complications were improved by symptomatic and supportive treatments. (3) Follow-up situation: among 1 045 patients, 558 received long-term follow-up, with follow-up time of 10-171 months and a median time of 79 months. Eight-four patients had stone recurrence. Of 13 patients with recurrence of extrahepatic bile duct stones, 7 took out stones by endoscopic retrograde cholangio pancreatography (ERCP) and 6 underwent reoperations. Of 71 patients with recurrence of intrahepatic bile duct stones, 43 underwent reoperations and 28 received conservative treatment. Conclusions Percutaneous sinus-tract cholangioscopy for residual intra- and extra-hepatic bile duct stones is safe and effective, with good diagnosis and treatment values and a high clerance rate. The integrity of T-tube sinus-tract is a key of complete stones removal. Key words: Hepatolithiasis; Residual stones; Cholangioscopy; Efficacy