Percutaneous Transhepatic Cholangioscopic Lithotomy Research Articles

Comparative study of the effect of U100 laser and pneumatic ballistic combined with percutaneous transhepatic cholangioscopic lithotomy in the treatment of intra-and extrahepatic bile duct stones and its effect on liver function.

Objectives:To compare the efficiency of U100 laser and pneumatic ballistics combined with percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) in the treatment of intra-and extrahepatic bile duct stones and their effects on liver function.Methods:Medical records of 97 patients with intra-and extrahepatic bile duct stones treated in our hospital from May 2020 to May 2021 were selected for retrospective analysis. Of them, forty-three patients received pneumatic ballistic lithotripsy combined with PTCSL (Group-I), and 54 patients received U100 laser lithotripsy combined with PTCSL (Group-II). The therapeutic effects of the treatment in two groups and its effect on liver function were compared and analyzed.Results:There was no significant difference in the operation time and intraoperative bleeding (P>0.05) between the two groups. The postoperative pain duration and hospital stay of patients treated with U100 laser lithotripsy combined with PTCSL (Group-II) were shorter than those treated with pneumatic ballistic lithotripsy combined with PTCSL (Group-I), P<0.05. The biliary bleeding rate of patients in Group-II was lower (3.70%) than those in Group-I (16.27%, P<0.05), and the stone residue rate of patients in Group-II was also lower (1.85%) than those in Group-I (11.63%, P<0.05). The levels of total bilirubin (TBIL), alanine aminotransferase (ALT) and albumin (ALB) in Group-II patients were higher than in patients in Group-I.(P<0.05).Conclusion:Compared with pneumatic ballistics, U100 laser lithotripsy combined with PTCSL in the treatment of intra and extrahepatic bile duct stones has the advantages of less postoperative pain, shorter hospital stay, less biliary bleeding and stone residue, and less damage to liver function.

Application of Laparoscopic Technique in the Treatment of Hepatolithiasis

Hepatolithiasis is commonly encountered in Southeastern and East Asian countries, and its incidence is increasing in Western countries. For symptomatic hepatolithiasis or asymptomatic hepatolithiasis with signs of liver atrophy or malignancy, surgical intervention is needed, especially when peroral cholangioscopy and percutaneous transhepatic cholangioscopic lithotomy are not suitable or fail to be performed. Currently, laparoscopic surgery is gradually replacing traditional open surgery and becoming a better option. Various types of laparoscopic surgeries, including laparoscopic hepatectomy, laparoscopic biliary exploration through the common bile duct or the hepatic duct stump, and robotic-assisted laparoscopic surgery, have been developed for the treatment of simple hepatolithiasis, hepatolithiasis concomitant with choledocholithiasis, recurrent hepatolithiasis, and complicated hepatolithiasis. The related clinical experience is gradually accumulating. In this review, the laparoscopic applications and their advantages will be summarized. In most cases, the laparoscopic technique could provide the advantages of less trauma, reduced blood loss, and faster postoperative recovery.

The Light at the End of the Tunnel

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

Management of Intrahepatic Duct Stone

Intrahepatic duct (IHD) stone is the presence of calculi within the intrahepatic bile duct specifically located proximal to the confluence of the left and right hepatic ducts. This stone is characterized by its intractable nature and frequent recurrence, requiring multiple therapeutic interventions. Without proper treatment, biliary strictures and retained stones can lead to repeated episodes of cholangitis, liver abscesses, secondary biliary cirrhosis, portal hypertension, and death from sepsis or hepatic failure. The ultimate treatment goals for IHD stones are complete removal of the stone, the correction of the associated strictures, and the prevention of recurrent cholangitis. A surgical resection can satisfy the goal of treatment for hepatolithiasis, i.e., complete removal of the IHD stones, stricture, and the risk of cholangiocarcinogenesis. On the other hand, in some cases, such as bilateral IHD stones, surgery alone cannot achieve these goals. Therefore, the optimal treatments require a multidisciplinary approach, including endoscopic and radiologic interventional procedures before and/or after surgery. Percutaneous transhepatic cholangioscopic lithotomy (PTCS-L) is particularly suited for patients at poor surgical risk or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. PTCS-L is relatively safe and effective for the treatment of IHD stones, and complete stone clearance is mandatory to reduce the sequelae of IHD stones. An IHD stricture is the main factor contributing to incomplete clearance and stone recurrence. Long-term follow-up is required because of the overall high recurrence rate of IHD stones and the association with cholangiocarcinoma.

Endoscopy Lithotomy for Intrahepatic Gallstones: A Meta-Analysis.

Endoscopy lithotomy (percutaneous transhepatic cholangioscopic lithotomy or through a T-tube track) has become a well-established treatment for intrahepatic gallstones. However, the relationship between strictures and the results of this treatment is still controversial. We searched PubMed, EMBASE, Cochrane Library databases, clinicaltrails, CBM, and Google scholar systematically for all articles. The rate of complete clearance, the recurrence rate, and major complications were analyzed. A meta-analysis was performed by RevMan 5.2. Thirteen studies were included. In patients with intrahepatic duct stricture, the rate of complete clearance was significantly lower, but the rate of recurrence was significantly higher. The morbidity rate of major complications was significantly lower in complete stone removal patients. Intrahepatic biliary stricture is a major cause of treatment failure for intrahepatic stones and stone recurrence. To prevent recurrent cholangitis or cholangiocarcinoma, complete removal of intrahepatic gallstones is very important.

Hepatolithiasis: analysis of Japanese nationwide surveys over a period of 40 years.

The aims of the present study are to clarify the changes in clinicopathologic features, diagnosis and treatment for hepatolithiasis, and propose an appropriate management strategy in Japan. The research group conducted nationwide surveys seven times in the past over a period of 40 years. Furthermore, a cohort was followed up in 2010. We analyzed the clinical features, diagnosis tools, treatment procedures, outcomes, and predictive factors for cholangiocarcinoma. Surgery was the primary method for hepatolithiasis up to 1998, and the frequency of its use has decreased since then. In 2011, 66.7% of hepatolithiasis patients were treated using nonsurgical approaches. In addition, endoscopic retrograde cholangiography (ERC) with stone extraction was the most frequently performed procedure (22.7%). However, the incidences of residual stone and recurrent stone after ERC with stone extraction were higher than those after percutaneous transhepatic cholangioscopic lithotomy and surgery. Bile duct stricture and dilatation during follow up were significant risk factors for stone recurrences. In the cohort study, stone removal only and age >65 years were significant factors for the development of cholangiocarcinoma. In patients without a history of cholangioenterostomy, left-lobe-type stones were a risk factor, and hepatectomy reduced the risk of the development of cholangiocarcinoma significantly. Nonsurgical treatment may be performed as the first-line treatment for hepatolithiasis. Surgery should be performed on patients who were treated incompletely after nonsurgical treatment. However, hepatectomy may be recommended for patients with left-lobe-type stones and without a history of cholangioenterostomy.

Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones

Background/AimsApproximately 5% to 10% of common bile duct (CBD) stones are difficult to remove by conventional endoscopic methods. Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) can be an alternative method for this condition, but is not well established yet. The aim of this study was to evaluate the clinical efficacy and safety of PTCSL for removal of difficult CBD stones.MethodsThis study is a retrospective review of 34 consecutive patients who underwent unsuccessful removal of CBD stones using conventional endoscopic methods between December 2008 and July 2010 and were subsequently treated using PTCSL.ResultsAmong 443 patients with CBD stones, 34 patients (7.8%) failed to achieve stone removal using conventional endoscopic methods. Of these 34 patients, 33 were treated using PTCSL. In all 33 cases (100%), complete stone removal was achieved using PTCSL. Most complications (15/17, 88.2%) were mild and transient. Major complications occurred in two patients (6.1%) who experienced hemobilia, and percutaneous transhepatic biliary drainage tract disruption, respectively; which were fully recovered without mortality.ConclusionsDespite prolonged hospital stay and temporary decline of quality of life, PTCSL is an effective and safe method in the management of difficult CBD stones, especially in patients with difficulty in approaching the affected bile duct.

Risk Factors for Long-term Outcomes after Initial Treatment in Hepatolithiasis

Hepatobiliary complications, such as stone recurrence, recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma may occur after treatment for hepatolithiasis. However, few previous studies have addressed the risk factors and long-term outcomes after initial treatment. Eighty-five patients with newly diagnosed hepatolithiasis, actively treated for hepatolithiasis, constituted the cohort of this retrospective study. Patients were treated by hepatectomy or nonoperative percutaneous transhepatic cholangioscopic lithotomy. Long-term complications, such as recurrent cholangitis, liver abscess, secondary biliary cirrhosis, and cholangiocarcinoma, and their relationships with clinical parameters were analyzed. The mean follow-up period was 57.4 months. The overall hepatobiliary complication rate after the treatment was 17.6%. Multivariate analysis of suspected risk factors showed that complications were associated with age (HR, 1.046; CI, 1.006-1.089), bile duct stricture (HR, 4.894; CI, 1.295-18.495), and residual stones (HR, 3.482; CI, 1.214-9.981). In conclusion, several long-term hepatobiliary complications occur after hepatolithiasis treatment, and regular observation is necessary in patients with concomitant biliary stricture or residual stones.

Percutaneous Approach for Removal of Difficult Common Bile Duct Stones

See Usefulness of Percutaneous Transhepatic Cholangioscopic Lithotomy for Removal of Difficult Common Bile Duct Stones by Jae Hyung Lee, Hyung Wook Kim, Dae Hwan Kang, et al., on page 65-70 Bile duct stone disease is one of the most common problems in medical practice. Surgical common bile duct (CBD) exploration was the procedure of choice for the treatment of bile duct stones a few decades ago. However, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy has become the treatment of choice for bile duct stones after the development of ERCP techniques. Development of devices and techniques used in endoscopic sphincterotomy and stone extraction has increased the success rate of stone removal. Meanwhile, endoscopic sphincterotomy may be difficult or impossible in some clinical situations, including duodenal or pyloric stenosis, unusual biliary anatomy, previous gastrointestinal surgery such as Billroth II and Roux-en-Y gastrojejunostomy reconstruction, bilioenteric anastomosis, and patients' intolerance. As a surgical modality, laparoscopic biliary surgery has been widely used. Laparoscopic CBD exploration (transcystic or transcholedochal) is the most commonly used method for managing difficult CBD stones. However, general anesthesia is necessary to perform the surgery and the cost of the procedure is high. The success rate in performing laparoscopic CBD exploration is approximately 86% to 95% with 5% to 18% complication rates.1 Percutaneous transhepatic stone removal is another important technique among the nonoperative managements of bile duct stones. Percutaneous transhepatic stone extraction and expulsion into the duodenum was first reported in 1979.2 Percutaneous transhepatic cholangioscopy (PTCS) can be combined with these techniques. Balloon dilatation of the sphincter of Oddi has been widely used to facilitate stone removal procedure in order to allow biliary stone passage. Several techniques including basket forceps, electrohydraulic lithotripsy (EHL), and laser lithotripsy are now available for fragmentation of large stones.3 Variable major and minor complications of this technique including cholangitis, biliary pleural effusion, and self-limiting hemobilia have been reported. Lee et al.4 reported 100% success rate of PTCS lithotomy for removal of difficult CBD stones in 33 cases. EHL was used in most patients. Complications related with PTCS lithotomy, including fever, pancreatitis, and hemobilia, occurred in 15 patients (45.5%) but were ameliorated with conservative management. The mean procedure number of PTCS lithotomy was 2.8 and the numbers of EHL session were one session in 16, two sessions in nine, three sessions in five, and more than four sessions in two patients. The major indications of PTCS were altered anatomy due to previous stomach surgery (16 cases) and impacted stones (11 cases). Fifteen patients had prior cholecystectomy, but the paper did not mention the presence of gallbladder stone in another 18 patients with intact gallbladder. Because PTCS is an invasive procedure, declining quality of life and requiring additional time for dilatation, maturation and repeated procedure, this procedure should be considered in really difficult cases in which duodenoscope insertion into ampulla is impossible. If biliary cannulation is possible but stone is impacted in CBD, we should know that there are emerging new techniques such as endoscopic biliary lithotripsy using FREDDY laser5 and direct peroral cholangioscopy (POC) with ultraslim endoscopy.6 Holmium laser lithotripsy under direct POC using an ultrathin upper endoscope was also reported as an effective and safe technique for removal of difficult CBD stones.7 Laparoscopic CBD exploration and cholecystectomy are another options if the patients have both gallbladder and CBD stones and medical conditions which are tolerable to general anesthesia. Lee et al.8 reported that laparoscopic CBD exploration is a safe and effective treatment modality for CBD stones not only for younger patients but also for elderly patients (over 70 years). They suggested the laparoscopic CBD exploration as the first treatment strategy for difficult CBD stones as there were no significant differences in mean operation time, postoperative hospital stay, first meal time, recurrence rate, remnant stone, and complication or mortality rates in both groups. Because this study on PTCS lithotomy4 was a retrospective study conducted between 2008 and 2010, new techniques were not considered and PTCS lithotomy was done in cases with impacted CBD stones regardless of biliary cannulation by conventional ERCP. Nevertheless, this paper confirmed that PTCS lithotomy is a safe and effective treatment modality in difficult CBD stones if conventional ERCP with lithotripsy was impossible.

Percutaneous Transhepatic Cholangioscopic Lithotomy of a Common Bile Duct Stone through the Gallbladder Route

Percutaneous Transhepatic Cholangioscopic Lithotomy of a Common Bile Duct Stone through the Gallbladder Route

Reappraisal of percutaneous transhepatic cholangioscopic lithotomy for primary hepatolithiasis

A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery. A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome. Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p < 0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p < 0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p < 0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p > 0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p > 0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p < 0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p < 0.01). The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis.

Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL. This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1-22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence. PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026). PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.

Long-term outcome of percutaneous transhepatic cholangioscopic lithotomy for hepatolithiasis

Objectives Percutaneous transhepatic cholangioscopic lithotomy (PTCSL) for the treatment of hepatolithiasis is particularly suited for those patients who are poor surgical risks or who refuse surgery and those with previous biliary surgery or stones distributed in multiple segments. However, hepatolithiasis is characterized by high rates of treatment failure and recurrence. We examined the long-term results of 245 patients with hepatolithiasis treated by PTCSL. Methods This was a retrospective study of 245 patients who underwent PTCSL for hepatolithiasis; the patients were followed for 1–22 yr to evaluate the immediate and long-term results. Sonography was used to search for stone recurrence every year or whenever the patients presented symptoms suggestive of cholangitis. Cholangiography and/or CT were performed to verify recurrence. Results PTCSL achieved complete clearance of hepatolithiasis in 209 patients (85.3%); the rate of incomplete clearance was higher in patients with intrahepatic duct stricture (29/118, 24.6% vs 7/127, 5.5%; p = 0.002). The rate of major complications was 1.6% (4/245) and included liver laceration (n = 2), intra-abdominal abscess (n = 1), and disruption of the percutaneous transhepatic biliary drainage fistula (n = 1). The overall recurrence rate of hepatolithiasis and/or cholangitis was 63.2%. The absolute rate of stone recurrence was not significantly related to the presence of intrahepatic duct stricture (51/89, 56.2% vs 53/120, 44.4%; p = 0.08), although the median time to recurrence was less in those with stricture (11 vs 18 yr; p = 0.007). In the patients without intrahepatic duct stricture, the rate of complete stone clearance was not related to the presence of dilation (34/38, 89.5% vs 86/89, 96.6%; p = 0.196), but the recurrence rate was higher in those with dilation (20/34, 58.8% vs 33/86, 38.4%; p = 0.042). Among the 209 patients with a successful initial PTCSL, the incidence of recurrent cholangitis or cholangiocarcinoma was significantly higher in those with incompletely removed recurrent hepatolithiasis than in those without coexisting hepatolithiasis (44.3%, 27/61 vs 16.2%, 24/148; p < 0.001 and 6.6%, 4/61 vs 0.7%, 1/148; p = 0.026). Conclusions PTCSL is a relatively safe and effective procedure for treating hepatolithiasis. Long-term follow-up is required because the overall recurrence rate of hepatolithiasis and/or cholangitis is high. The rate of complete stone clearance and the median time to stone recurrence are less in the presence of stricture, but the absolute rate of stone recurrence is not significantly related to stricture. In the absence of stricture, the rate of stone recurrence is higher in patients with dilated intrahepatic duct. Complete stone clearance is necessary, because the incidence of recurrent cholangitis or cholangiocarcinoma is higher in patients with incomplete clearance of recurrent hepatolithiasis.

Vascular complications in percutaneous transhepatic management of complicated hepatolithiasis with difficult intrahepatic biliary strictures: are they avoidable?

Little has been reported about hemobilia in the management of complicated residual or recurrent hepatolithiasis with intrahepatic biliary strictures by percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy. To analyze retrospectively the incidence, possible factors, and management of hemobilia in such patients, a consecutive series of 177 patients was studied from 1983 to 2001: 90 patients in the early, 7.5-year period and 87 patients in the later period, in which some procedures were modified. Minor hemobilia occurred during percutaneous puncture in 6 patients: 4 (4.4%) in the early period and 2 (2.3%) in the later period. Massive hemobilia developed in 14 patients (15.5%) in only the early period, during stricture dilation, lithotripsy, or lithotomy. Immediate arteriography revealed arterial bleeding (7), extravasation (3), pseudoaneurysm (3), or an undetermined source (1). Transcatheter arterial intervention enabled successful hemostasis. Massive hemobilia is a potential serious complication of percutaneous stricture dilation and percutaneous transhepatic cholangioscopic lithotomy but is avoidable.

Comparison of treatments for hepatolithiasis: hepatic resection versus cholangioscopic lithotomy

Background: Hepatic resection and percutaneous transhepatic cholangioscopic lithotomy (PTCSL) are the two main approaches to the treatment of hepatolithiasis, but comparisons of longterm followup results have not been adequately reported. Study Design: Of 86 patients with hepatolithiasis admitted to our institution between 1980 and 1996, we reviewed 54 patients: 26 who underwent hepatic resection and 28 who underwent PTCSL. Five patients who underwent postoperative cholangioscopic lithotomy were included in the former group. The remainder of the hepatolithiasis patients were not treated by hepatic resection or PTCSL and, therefore, were excluded from this study. Hepatic resections were mainly indicated for left-sided localized intrahepatic calculi, atrophic liver, and possible presence of cholangiocellular carcinoma. PTCSL was performed for right-sided, bilateral or recurrent stones at an average of 6 treatments (range 1 to 20 treatments) for each patient. There were no differences between the two groups in terms of gender or age. The recurrence rate of stones and longterm prognosis were analyzed using the Kaplan-Meier method, and other clinical factors listed below were statistically compared. Results: The rate of complete removal of stones was similarly high in each group (96.2% in the hepatic resection group versus 96.4% in the PTCSL group). The complication (38.5% versus 21.4%) and 5-year survival (85.6% versus 100%) rates were comparable. Remaining bile duct stricture (18.2% versus 60.9%, p < 0.01) and 5-year recurrence rates (5.6% versus 31.5%, p < 0.05) were statistically lower in the hepatic resection group than in the PTCSL group. Conclusions: Hepatic resection, when combined with postoperative cholangioscopic lithotomy, is a preferable treatment for left-sided stones with strictures and bilateral stones.

Complications after cyst excision with hepaticoenterostomy for choledochal cysts and their surgical management in children versus adults

The aim of this study was to review the cases 200 children and 40 adults who had cyst excision combined with hepaticoenterostomy (CEHE) for choledochal cyst, with particular emphasis on post-CEHE complications and their surgical management. Patients who had CEHE at the age of 15 years or less were defined as children, and those aged 16 years or older were defined as adults. The mean age when patients became initially symptomatic was 3 years in children and 26 years in adults. Eleven adults became symptomatic as children (≤ 15 years of age). The mean age of CEHE in children and adults was 4.2 years and 35 years, respectively. The time interval between the onset of inital symptoms and CEHE was significantly less in children than in adults ( P < .0001). Of the 200 children, 176 had primary CEHE, and 24 had secondary CEHE converted from cystoenterostomy or other biliary surgery. Seventy children had intraoperative cyst endoscopy, which enabled us to examine the proximal intrahepatic bile ducts for stenosis and debris, and to wash out debris, protein plugs, and stones from the intrapancreatic ducts. Of the 40 adults, 22 had primary CEHE, 18 had secondary CEHE. The mean follow-up period was 10.9 years in children and 10.7 years in adults. The number of patients with post-CEHE complications in children and adults was 18 (9.0%) and 17 (42.5%), respectively. The post-CEHE complication rate in children was significantly lower than in adults ( P < .0001). The 18 children had 25 post-CEHE complications such as cholangitis, intrahepatic bile duct stones, pancreatitis, stone formation in the intrapancreatic terminal choledochus or pancreatic duct, and bowel obstruction. Twentyseven post-CEHE complications developed in the 17 adults including 2 cases of cholangiocarcinoma. There were no post-CEHE complications in the 70 children who had intraoperative cyst endoscopy. No stone formation was seen in the 145 children who had CEHE at the age of 5 years or less. Eight stone formations were seen in seven (12.7%) of the remaining 55 children aged over 5 years. Stones developed in seven (17.5%) adults. The incidence of post-CEHE stone formation in children aged 5 years or less was significantly lower than in other children and adults ( P < .0001). Reoperation was required in 15 children: revision of hepaticoenterostomy in 4, percutaneous transhepatic cholangioscopic lithotomy (PTCSL) in 1, excision of intrapancreatic terminal choledochus in 2, endoscopic sphincterotomy of the papilla of Vater in 1, pancreaticojejunostomy in 1, and laparotomy for bowel obstruction in 6. Ten adults required reoperations: revision of hepaticoenterostomy in 2, PTCSL in 2, left hepatic lobectomy in 1, endoscopic sphincterotomy in 2, exploratory laparotomy in 2, and adhesiolysis in 1. The authors conclude that early diagnosis followed by CEHE is the treatment of choice for choledochal cyst, and intraoperative cyst endoscopy is recommended as a valuable adjunct to CEHE.

Percutaneous trans-hepatic cholangioscopic lithotomy for hepatolithiasis: long-term results

A prospective study was undertaken to evaluate the long-term results of percutaneous trans-hepatic cholangioscopic lithotomy in 48 patients with hepatolithiasis during a 4- to 10-year follow-up period. Complete clearance of the intrahepatic stones was achieved in 40 patients (83.3%). In these 40 patients, long-term results during the follow-up period were as follows: free of symptoms and without evidence of recurrent stones, 22 patients (55%); free of symptoms with recurrent stones, 2 patients; recurrent stones with cholangitis, 14 patients (35%); symptoms of cholangitis without evidence of recurrent stones, 2 patients. Of those patients with recurrent stones, secondary biliary cirrhosis developed in 1, and in 9 of the patients in whom secondary cholangitis developed, subsequent laparotomy or percutaneous drainage was required. Three of the 40 patients (7.5%) died within the 4- to 10-year follow-up period. The procedural failure rate in terms of stone retention was 20.5% for patients with bile duct strictures. No stones were retained in patients without strictures. The postprocedural rate of stone recurrence for patients with bile duct strictures was 51.6%; no recurrence was seen in patients without strictures. (Gastrointest Endosc 1995;42:1-5.)

Limitations of percutaneous transhepatic cholangioscopy in the removal of complicated biliary calculi.

To investigate the limitations of percutaneous transhepatic cholangioscopic lithotomy (PTCSL) in the management of retained or reformed biliary calculi, we conducted a retrospective study of 50 patients who had received PTCSL for complicated biliary calculi during a period of 32 months. The calculi were located in the common bile duct (24%), the intrahepatic bile ducts (60%), and in both the common bile duct and intrahepatic bile ducts (16%). The adjunctive techniques in PTCSL included balloon dilatation for the biliary stricture, electrohydraulic lithotripsy (EHL) for crushing large impacted stones, and flushing techniques, biliary spoons, and basket catheters for stone fragmentation and grasping. The overall percutaneous manipulations totaled 221 procedures, including 124 sessions of PTCS. In each patient, the number of sessions of PTCS varied from 1 to 7. In our series, the main complications of PTCS therapy, rarely reported in the literature, included pain intolerance in 7 cases (14%), minor bleeding in 7 cases (14%), and massive bleeding which needed angiographic diagnosis and therapy for hemostasis in 5 cases (10%). Secondary biliary cirrhosis, severe biliary stricture and angulations, previous shunt surgery, neovascularization surrounding the chronic inflammatory stenotic intrahepatic bile ducts, pseudoaneurysm formation, and coexistent cholangiocarcinoma contributed to the vulnerability of bleeding during manipulations. The complications resulted in treatment failure in 11 patients (22%). We conclude that PTCS is a useful alternative treatment to surgery for biliary calculi, but it has limitations that obviate complete stone clearance.