The Light at the End of the Tunnel

Abstract

Roughly 5-10% of common bile duct (CBD) stones cannot be removed by conventional methods owing to alterated anatomy. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) has been cited as a viable alternative to these difficult situations. Because PTC is time consuming, more involved, and requires expertise it is an often underutilized technique for stone removal. We present to you a case of PTSCL in the setting of a complex clinical situation. A 69 year old female with a history of Roux-En-Y surgery presented with a 3 week history of abdominal pain and jaundice. Her labs revealed a total bilirubin of 5.3 mg/dL. Alkaline phosphatase 1293 mg/dL, ALT 79 mg/dL, and AST 121 mg/dL. On a CT scan she had a intraductal polypoid lesion 1.7 x 2 x 1.8 cm obstructing the CBD with 1.7cm dilation. She underwent single balloon ERCP however cannulation of the CBD was unsuccessful. A PTC drain was placed and a cholangiogram revealed severe biliary ductal dilation with a polypoid filling defect within the inferior CBD. The patient then returned to the hospital with sepsis from multiple sources including C. Diff, UTI, and peritonitis. Because of her clinical condition she was not deemed to be a surgical candidate and thus she underwent cholangioscopic examination via her PTC drain. A 12 French sheath was advanced over a wire into the common bile duct to the level of the abrupt cut off. A cholangioscope was advanced and demonstrated an obstructing stone measuring approximately 25 mm in diameter and several centimeters in length. Lithotripsy was then performed shattering the stone. The ampulla was then balloon dilated and a balloon was then used to push the contents within the common bile duct into the small bowel. This was process was repeated several times with serial dilations of the ampulla. The patient improved and was sent home. Though PTCSL is a challenging procedure, it is an alternative to conventional methods for several reasons. In groups who are experienced with PTC, the rate of successful stone removal is close to 90%. In addition, the complication rates can be equivocal to ERCP complications, and less than laparoscopic assisted techniques. Finally, cholangioscopy does not require dilation of the biliary tree making this procedure advantageous in comparison to other techniques. This case serves to corroborate the efforts of other case series showing PTCSL to be an enticing alternative to removing CBD stones in patients with surgically altered anatomy.1374_A.tif Figure 1: CBD obstruction1374_B.tif Figure 2: CBD obstruction1374_C.tif Figure 3: Dr. Mizrahi using SpyGlass