Transhepatic Approach Research Articles

Percutaneous trans-hepatic approach to address common bile duct stone (CBDS) in patients who had laparoscopic Roux-en-Y gastric bypass (LRYGB)

Percutaneous trans-hepatic approach to address common bile duct stone (CBDS) in patients who had laparoscopic Roux-en-Y gastric bypass (LRYGB)

Techniques of Biliary Reconstruction in the Management of Biliary Stricture for Liver Trauma: Usefulness of the Transhepatic Approach

Techniques of Biliary Reconstruction in the Management of Biliary Stricture for Liver Trauma: Usefulness of the Transhepatic Approach

Feasibility and safety of EUS-guided selective portal vein embolization with a coil and cyanoacrylate in a live porcine model.

Background and Objectives:Preoperative portal vein (PV) embolization using the percutaneous transhepatic approach has been performed in patients with hepatobiliary malignancy before extensive liver resection. The aim of this study is to evaluate the technical feasibility and initial safety of EUS-guided selective PV embolization using a coil and cyanoacrylate in a live porcine model.Methods:EUS-guided selective intrahepatic PV embolization with a coil and cyanoacrylate was performed in 9 pigs. The selected PV was punctured with 19G fine-needle aspiration (FNA) needle, and the coil was inserted under EUS-guidance. The cyanoacrylate was then immediately injected through the same FNA needle. The blood flow change in the embolized PV was evaluated using color Doppler EUS. A necropsy was performed following the 1-week observation period.Results:The success rates for the coil and cyanoacrylate delivery were 88.9% (8/9) and 87.5% (7/8), respectively. In 1 case, the coil migrated into the hepatic parenchyma. In another case, the cyanoacrylate injection failed due to early clogging in the FNA needle. There was a complete blockage of blood flow confirmed by color Doppler EUS in the embolized PV after coil and cyanoacrylate treatment. There was coil migration into the hepatic parenchyma in 1 case. There was no animal distress observed during the 1-week observation period before necropsy. The necropsy showed no evidence of damage to the intra-abdominal organs, and the selected PV was totally occluded with embolus.Conclusion:The study findings indicate EUS-guided selective PV embolization is both technically feasible and initially safe in an animal model.

T-PA power-pulse spray with rheolytic mechanical thrombectomy using cross-sectional image-guided portal vein access for single setting treatment of subacute superior mesenteric vein thrombosis.

Background:Isolated superior mesenteric vein (SMV) thrombosis is a rare but potentially fatal condition if untreated. Current treatments include transjugular or transhepatic approaches for rheolytic mechanical thrombectomy and subsequent infusions of thrombolytics. Tissue plasminogen activator (t-PA) power-pulse spray can provide benefit in a single setting without thrombolytic infusions. Computed tomography (CT) guidance for portal vein access is underutilized in this setting.Materials and Methods:Case 1 discusses acute SMV thrombosis treated with rheolytic mechanical thrombectomy alone using ultrasound guidance for portal vein access. Case 2 discusses subacute SMV thrombosis treated with the addition of t-PA power-pulse spray to the rheolytic mechanical thrombectomy, using CT guidance for portal vein access.Results:With rheolytic mechanical thrombectomy alone, the patient in Case 1 had significant improvement in abdominal pain. Follow-up CT demonstrated no residual SMV thrombosis and the patient continued to do well in long-term follow-up. With the addition of t-PA power-pulse spray to rheolytic mechanical thrombectomy, the patient in Case 2 with subacute SMV thrombosis dramatically improved postprocedure with resolution of abdominal pain. Follow-up imaging demonstrated patency to the SMV and partial resolution of thrombus. The patient continued to do well at 2-year follow-up.Conclusions:Adding t-PA power-pulse spray to rheolytic mechanical thrombectomy can provide benefit in a single setting versus mechanical thrombectomy alone and prevent the need for subsequent infusions of thrombolytic therapy. CT guidance is a useful alternative of localization for portal vein access via the transhepatic route that is nonoperator-dependent and helpful in the case of obese patients.

Expanding Endourologic Urolithiasis Techniques to Biliary Stones: Percutaneous Transhepatic Lithotripsy

Abstract Introduction and Objective: Choledocolithiasis is a significant problem that can lead to severe cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment. However, this is not always possible when the patient has surgically altered anatomy or very large stone burden. Urologists can use our skills and technology to assist in these situations. We report our technique and outcomes from our 15 years of experience with percutaneous transhepatic endoscopic biliary lithotripsy. Methods: Patients are selected by our gastroenterology colleagues who approach us for assistance when ERCP is not possible. We utilize a percutaneous transhepatic endoscopic approach in a combined procedure with interventional radiology. Most patients have a transhepatic biliary drain already in place. A wire is then placed through the tube into the biliary system and into the common bile duct. A 14F ureteral access sheath is placed under fluoroscopic guidance into the common bile duct. A flex...

Palliative Percutaneous Biliary Interventions in Malignant High Bile Duct Obstruction.

The optimal palliative intervention for malignant biliary obstruction is internal drainage by placement of a metallic stent. For patients with hilar biliary obstruction or low bile duct obstruction in whom endoscopy is not feasible, a percutaneous transhepatic approach in interventional radiology is preferred. This article reviews the rationale for this approach, periprocedural management, and techniques to optimize stent patency.

Surgical Approach to “Right Hepatic Core”: Deepest Region Surrounded by Major Portal Pedicles and Right Hepatic Vein

Background/Aims: The resection of hepatic tumors located in the region surrounded by the right hepatic vein (RHV) and the portal pedicles of the right paramedian/lateral sector (the right hepatic core) remains a challenge for liver surgeons. The aim of this study was to demonstrate the surgical techniques and outcomes of our atypical-parenchyma-sparing hepatectomy (atypical-PSH) approach for the removal of tumors in the right hepatic core. Methods: Perioperative records of 1,179 consecutive patients who had undergone hepatectomy for hepatocellular carcinoma or colorectal liver metastases from January 2006 to December 2014 were retrospectively reviewed. Results: Twenty-six patients (2%) had a tumor in the right hepatic core. Among them, 20 patients underwent atypical-PSH, including the anterior approach (resection of the right paramedian hepatic parenchyma, n = 9), posterior approach (resection of the right lateral hepatic parenchyma, n = 10), and transhepatic approach (tumor enucleation from the raw surfaces along the RHV, n = 1). Their postoperative outcomes were similar to the remaining 6 patients who had undergone right hepatectomy. Conclusions: Atypical-PSH can be safely applied for the removal of tumors in the right hepatic core. This technique may have potential advantages in preserving hepatic function for postoperative chemotherapy and repeated hepatectomy for future recurrence.

Clinical efficacy of the combination of transjugular intrahepatic portosystemic shunt and catheter-directed thrombolysis in the treatment of acute portal vein thrombosis accompanied by Budd-Chiari syndrome with extensive occlusion of hepatic veins

Objective To evaluate the clinical efficacy of combination of transjugular intrahepatic portosystemic shunt (TIPS) and catheter-directed thrombolysis (CDT) in the treatment of acute portal vein thrombosis (PVT) accompanied by Budd-Chiari syndrome (BCS) with extensive occlusion of the hepatic veins. Methods From March 2013 to December 2015, nine patients of acute PVT accompanied by BCS with extensive occlusion of the hepatic veins were collected, and the patients were treated by the combination of TIPS and CDT. The clinical symptoms, liver function and portal vein hemodynamics of patients were observed. After operation, portal vein and shunt patency was followed up by Doppler ultrasound. The patients were followed up seven days, one, three, six months, and every six months after the operation. Paired sample t test was performed for statistically analysis. Results The study enrolled nine patients, six male and three female, with an average age of (41.6±10.9) years old. Operation was successfully performed in eight patients, and of whom three were completed under the assist of perctaneous transhepatic approach. After operation, the blood flow of portal vein was unobstructed and clinical symptoms of portal vein hypertension were obviously improved. There was no significant difference in portal vein diameter between pre-operation ((13.6±2.1) cm) and seven days ((12.5±1.7) cm), one month ((12.1±2.9) cm), three months ((12.9±3.2) cm), six months ((11.6±1.8) cm) after operation (all P>0.05). And the portal vein velocity after operation were (79.3±14.6), (84.4±17.3), (87.3±21.4) and (80.1±12.6) cm/s, respectively, which were higher than that before operation ((9.8±3.1) cm/s), and the differences were statistically significant (t=28.169, 34.713, 36.519, 30.314, all P<0.01). The maximum cross sectional area ratios of the thrombus to the lumen after operation were (17.1±6.9)%, (19.1±6.2)%, (16.2±5.5)% and (16.7±5.1)%, respectively, which were lower than that before operation ((78.2±14.5)%), and the differences were statistically significant (t=26.182, 23.931, 29.371, 27.471, all P<0.01). At the seventh day after operation, the pressure of portal vein decreased from (42.2±8.9) cmH2O (1 cmH2O=0.098 kPa) to (19.6±4.2) cmH2O (t=17.410, P<0.01). At seven days, one month, three months and six months after operation, albumin levels ((30.7±3.9), (30.9±4.2), (29.9±3.1) and (33.1±4.7) g/L) were all higher than that before operation ((26.5±4.8) g/L), and the differences were statistically significant (t=4.785, 4.874, 2.874, 5.402, all P<0.05). The levels of transaminase after operation (32.9±21.6), (39.5±22.4), (24.8±19.8), (37.1±26.9) U/L) were all lower than that before operation ((99.6±31.7) U/L), and the differences were statistically significant (t=27.624, 24.913, 33.671 and 25.019, all P<0.01). During eight to 17 months follow-up, TIPS stent shunt stenosis was found in one case at three months after operation and the blood flow recovered after treatment of balloon dilation. The shunt and blood flow of portal vein of the other seven cases were clear. None of the eight patients had the symptoms of hepatic encephalopathy and pulmonary embolism. Operation was not successfully performed in one case, and 29 days later the patient died of hepatic and renal failure. Conclusion The combination of TIPS and CDT is safe and effective in the treatment of acute PVT accompanied by BCS with extensive occlusion of the hepatic veins, which maintain the blood flow of portal vein clear during short-and medium-term follow-up. Key words: Budd-Chiari syndrome; Portal vein thrombosis; Portasystemic shunt, transjugular intrahepatic

Biliary Complications in Recipients of Living-Donor Liver Transplant: A Single-Center Review of 120 Patients.

Biliary complications are common after living-donor liver transplant. This retrospective study reviewed our experience with biliary complications in recipients of living-donor liver transplant. Over our 9-year study period, 120 patients underwent living-donor liver transplant. Patients were divided into 2 groups, with group A having biliary complications and group B without biliary complications. Both groups were compared, and different treatment modalities for biliary complications were evaluated. Group A included 45 patients (37.5%), whereas group B included 75 patients (62.5%). Biliary complications included bile leak in 17 patients (14.2%), biliary stricture in 11 patients (9.2%), combined biliary stricture with bile leak in 15 patients (12.5%), and sphincter of Oddi dysfunction and cholangitis in 1 patient each (0.8%). Cold ischemia time was significantly longer in group A (P = .002). External biliary drainage was less frequently used in group A (P = .031). Technical success rates of endoscopic biliary drainage and percutaneous transhepatic biliary drainage were 68.3% and 41.7%. Survival rate following relaparotomy for biliary complications was 62.5%. Graft ischemia is an important risk factor for biliary complications. Bile leaks can predispose to anastomotic strictures. The use of external biliary drainage seems to reduce the incidence of biliary complications. Endoscopic and percutaneous trans-hepatic approaches can successfully treat more than two-thirds of biliary complications. Relaparotomy can improve survival outcomes and is usually reserved for patients with intractable biliary complications.

The value of percutaneous transhepatic treatment of biliary strictures following pediatric liver transplantation.

ObjectiveTo evaluate the percutaneous transhepatic approach to the treatment of biliary strictures in pediatric patients undergoing liver transplantation.Materials and MethodsThis was a retrospective study of data obtained from the medical records, laboratory reports, and imaging examination reports of pediatric liver transplant recipients who underwent percutaneous transhepatic cholangiography, because of clinical suspicion of biliary strictures, between 1st September 2012 and 31 May 2015. Data were collected for 12 patients, 7 of whom were found to have biliary strictures.ResultsIn the 7 patients with biliary strictures, a total of 21 procedures were carried out: 2 patients (28.6%) underwent the procedure twice; 3 (42.8%) underwent the procedure three times; and 2 (28.6%) underwent the procedure four times. Therefore, the mean number of procedures per patient was 3 (range, 2–4), and the average interval between them was 2.9 months (range, 0.8–9.1 months). The drainage tube remained in place for a mean of 5.8 months (range, 3.1–12.6 months). One patient presented with a major complication, hemobilia, which was treated with endovascular embolization. Clinical success was achieved in all 7 patients, and the mean follow-up after drain removal was 15.4 months (range, 5.3–26.7 months).ConclusionThe percutaneous transhepatic approach to treating biliary strictures in pediatric liver transplant recipients proved safe, with high rates of technical and clinical success, as well as a low rate of complications.

Preliminary clinical efficacy of percutaneous transcystic papilla balloon dilation for removing common bile duct stones

Objective: To evaluate the feasibility, safety, and preliminary efficacy of percutaneous transcystic papilla balloon dilation for the common bile duct stones. Methods: A total of 11 patients with the common bile duct stones without dilatation of the intrahepatic bile ducts treated with percutaneous transcystic papilla balloon dilation in multiple center from April 2013 to May 2015 were analyzed retrospectively.In these 11 patients, there were 3 males and 8 females.And the average age was 68(52-91) years old.All patients had no obviously dilated intrahepatic bile duct, 6 patients were not suitable for endoscopic treatment or surgery, 4 patients refused endoscopic or surgical treatment and 1 patient had a history of failed endoscopic treatment.The white blood cell count, CA19-9, total bilirubin, direct bilirubin, AST, ALT and serum amylase level were recorded before the procedure, 1 week, and 1 month later.Early complications, such as cholangitis, pancreatitis, hemorrhage, and perforation were evaluated. Results: Technical success was achieved in all the 11 cases.The level of CA19-9, total bilirubin and direct bilirubin decreased significantly 1 week and 1 month after the procedure.One patient suffered from biliary tract infection.No severe complications, such as perforation of biliary or gastrointestinal tract, occurred during the follow up.Common bile duct stone recurred in 1 patient 2 years after the procedure. Conclusions: For cases who are not suitable for endoscopic treatment, surgery, or percutaneous transhepatic approach to treat the common bile duct stones, percutaneous transcystic papilla dilation is technically feasible and safe, and seems to be an appropriate alternative strategy.

One case of concurrent hemorrhage after pancreatic islet transplantation by percutaneous transhepatic portal approach

The percutaneous transhepatic portal approach is the most commonly used technique for islet transplantation, largely owing to its safety and minimally invasive characteristic. Bleeding complications after islet transplantation are rare. A case of type 1 diabetes mellitus (T1DM) was treated in Tianjin First Center Hospital, who had a massive intra-abdominal hemorrhage after percutaneous transhepatic portal vein catheterization for islet transplantation. Through the review of the overall development of the case, we aim to improve the awareness of the complications of islet transplantation, to reduce the incidence of complications after percutaneous transhepatic portal vein transplantation, and to provide experience.

Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches.

We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction. We retrospectively assessed 53 patients (33 men and 20 women; mean age, 58.7±15 years) who underwent stent placement between February 2004 and April 2014. All patients had unresectable tumors. The most common causes of obstruction were gastric (38%) and pancreatic cancers (36%). Uncovered self-expandable metallic stents (SEMS) were placed under fluoroscopic guidance. In addition to transoral approach in 46 patients (86.7%), transgastric and transhepatic approaches were used in six patients (11.3%) and one patient (1.8%), respectively. Gastric outlet obstruction scoring system (GOOSS) was used to evaluate oral intake before and after stenting. Patients were followed until death or the end of the study. Technical and clinical success rates were 100% and 92%, respectively. The median stent patency was 76 days (range, 4-985 days). Mean preprocedural GOOSS score of 0.1 increased to postprocedural GOOSS score of 2.42 (P < 0.001). Afferent loop decompression was achieved in one symptomatic patient. Neither mortality nor major complications occurred due to stenting. Stent migration occurred in one patient (2%) and stent obstruction occurred in two patients (4%). Combined biliary and duodenal stenting were performed in 21 patients (40%). Post-stenting GOOSS scores were predictive of survival (P = 0.003). Fluoroscopic metallic stent placement for palliation of malignant gastroduodenal obstruction is safe and effective with high technical and clinical success rates and minimal complications. High technical success rates can be achieved using different approaches.

Endoscopic ultrasonography-guided biliary drainage: A meta-analysis of publications with fifty or more patients

Background and Objectives:Endoscopic ultrasound-guided biliary drainage (EUS-BD) is an alternative to percutaneous drainage when endoscopic retrograde cholangiopancreatography (ERCP) is not possible or has failed. This was a meta-analysis determining the success and safety of EUS-BD and comparing techniques.Methods:Full-text publications where more than 50 patients were reported were included. Primary outcomes were technical success, clinical success, and overall complications. Secondary outcomes were incidence of bile leaks, bleeding, cholangitis, perforation, pneumoperitoneum, and death.Results:Nine trials were included (576 patients). EUS-BD had a technical success of 89.45% (95% confidence interval [CI], 81.26, 97.63), clinical success 81.69% (95% CI, 65.30, 98.08), total complications 20.58% (95% CI, 10.26, 30.89), bile leaks 5.97% (95% CI, 2.23, 9.71), bleeding 4.8% (95% CI, 0.15, 9.45), cholangitis 3.18% (95% CI, 1.39, 4.96), perforation 1.56% (95% CI, 0.30, 2.82), pneumoperitoneum 3.53% (95% CI, 0.73, 6.33), and death 1.6% (95% CI, 0.00, 3.50). Comparing EUS-choledochoduodenostomy (EUS-CDS) to EUS-hepaticogastrostomy (EUS-HG), the latter had a higher rate of overall complications, odds ratio (OR) 2.04 (95% confidence interval [CI], 1.21, 3.44). There was no difference comparing EUS-CDS versus EUS rendezvous (EUS-RV), EUS-CDS versus EUS antegrade stenting, or EUS-HG versus EUS-RV. Hepatic access versus extrahepatic access had a higher complication, OR 1.49 (95% CI, 1.02, 2.07).Conclusions:A transhepatic approach and EUS-HG might have a higher overall complication rate, but data are limited.

Endoscopic ultrasonography-guided intrahepatic portal vein embolization in an animal model

Background and Objectives:Preoperative portal vein embolization (PVE) by percutaneous transhepatic approach has been performed in candidates of major liver resection including right hepatectomy and extended right hepatectomy. This procedure can increase volume of remnant liver and prevent postoperative hepatic failure. The aim of this animal study is to evaluate the technical feasibility and safety of endoscopic ultrasonography (EUS)-guided intrahepatic PVE.Methods:EUS-guided intrahepatic PVE with coil and histoacryl was performed in seven pigs under general anesthesia using linear array echoendoscope. The intrahepatic portal vein (PV) was punctured with a 19-gauge FNA needle, and an embolization coil was inserted into the selected intrahepatic PV. Then, histoacryl was injected through the same FNA needle. The blood flow change in the selected intrahepatic PV was evaluated by color Doppler EUS. After 1-week observation period, necropsy was performed.Results:Embolization coil was placed in the selected intrahepatic PV successfully in six of seven animals, and Histoacryl injection was successful in five of them. In one case, histoacryl injection was failed due to needle deflection and early clogging. After coil insertion and histoacryl injection, disappearance of blood flow in the treated intrahepatic PV was confirmed by color Doppler. There was no adverse event in six animals during 1-week observation period. Necropsy revealed no evidence of damage to the treated intrahepatic PV and intra-abdominal organs.Conclusions:EUS-guided intrahepatic PVE can be both technically feasible and safe in a live porcine model. Further animal studies are needed to demonstrate the efficacy and long-term safety of this challenging intervention.

Abdominal ultrasound in children - are we careful enough when it comes to lung bases?

Objective - To investigate the frequency of positive findings within the lung bases during abdominal ultrasound (US) examinations in children with referral diagnosis not suggesting pulmonary disease. Materials and methods - A retrospective study included all children with abdominal US performed within 2 years by a single pediatric radiologist in the regional children's hospital. Of all examined children, 22 (mean 7.4 y, SD=4.2 y) had pathological findings detected within the lung bases, without referral diagnosis suggesting a pulmonary pathology. Each abdominal US included a trans-abdominal (trans-hepatic and trans-splenic) approach to both lung bases. Results - While performing abdominal US a detected pulmonary pathology included: 19 pneumonias and 3 pleuropneumonias, with the most common referral diagnosis being abdominal pain (15 children), followed by nausea and vomitting (3 children), febrile convulsiones (2 children), exacerbation of juvenile arthritis (1), and a routine follow-up a day after hydrostatic reduction of ileocolic intussusception (1). In outpatients with referral diagnosis of abdominal pain, 0.95% had positive lung base US findings. Conclusion - Each radiologist should be aware of the potential pathological finding within the lung bases when performing abdominal ultrasound in children. Its detection might have a serious impact on the patient's treatment.

Transhepatic Approach along Right or Left Portal Fissure for Resections of Deeply Located Small Liver Tumors: A Novel Approach to “The Hepatic Core”

Transhepatic Approach along Right or Left Portal Fissure for Resections of Deeply Located Small Liver Tumors: A Novel Approach to “The Hepatic Core”

Abstract 602: Development of Cell Therapy in Severe Familial Hypercholesterolemia

Familial hypercholesterolemia (FH) patients are characterized by high LDL cholesterol levels in the blood and premature cardiovascular disease. Although most of heterozygous FH patients are able to be treated with statin, ezetimibe and bile acid sequestrants and anti-PCSK9 antibodies, homozygous FH patients are resistant to drug therapy. Therefore, many of homozygous FH patients used to be treated by LDL-apheresis. However, the effect of removing LDL cholesterol is still not sufficient and definitive therapies need to be developed. With the increase of the evidence about the safety of mesenchymal stem cells and percutaneous transhepatic portal approach in islet transplantation, we have developed a cell transplantation therapy with allogeneic adipose tissue-derived multilineage progenitor cells, as an alternative treatment instead of liver transplantation. We have generated a protocol for the phase 1 clinical study. The primary endpoint should be safety evaluation including allergic reaction, rejection reaction, thrombosis and complications in the blood vessel by cell-transplantation. The secondary endpoint should be the efficacy including changes in serum lipid such as LDL-C, TC, HDL-C, TG and Lp(a), and Secession possibility of LDL-apheresis. We transplanted the first case in February, 2016. Then we are collecting clinical data. We would demonstrate the current status and the issues to be solved for the following study.

Safety and effectiveness of percutaneous cholecystostomy in critically ill children who are immune compromised.

Acalculous cholecystitis is known to develop in critically ill patients without cystic duct obstruction. In the past, treatment for acalculous cholecystitis has been cholecystectomy; however, many children who are critically ill are Percutaneous cholecystostomy is likely the procedure of choice in this subgroup of patients. To assess the safety and effectiveness of percutaneous cholecystostomy in critically ill and immune-compromised children with acalculous cholecystitis. Retrospective review of immune-compromised and critically ill children who underwent percutaneous cholecystostomy between 2006 and 2013. Diagnostic imaging performed included ultrasound, CT and hepatobiliary scintigraphy. Every percutaneous cholecystostomy was performed using imaging guidance. Ten critically ill and immune-compromised children with acalculous cholecystitis underwent percutaneous cholecystostomy. Seven boys and 3 girls, ranging in age from 10months to 15years 8months, were treated. Six of the immune-compromised children had received a bone marrow transplant for leukemia (5 children) or severe combined immunodeficiency (SCID) (1 child), and ranged from 18 to 307days post bone marrow transplant at the time of their percutaneous cholecystostomy. Of the remaining four immune-compromised children with acalculous cholecystitis who underwent percutaneous cholecystostomy, two had leukemia, one had SCID and lymphoma, and the fourth was undergoing treatment for undifferentiated germ cell tumor. The 10 percutaneous gallbladder drains were placed using a transhepatic approach, except one unintentional transperitoneal approach. There were no complications. Three gallbladder drains were removed in Interventional Radiology. Those three patients had a return to normal gallbladder function and didn't require cholecystectomy. Two drains were removed during cholecystectomy and another as an outpatient. Four patients died in the hospital due to multiorgan system failure, with indwelling gallbladder drains. Percutaneous cholecystostomy is a safe procedure in immune-compromised and critically ill children with acalculous cholecystitis. Percutaneous cholecystostomy may obviate the need for future cholecystectomy.

Lithotripsy of Biliary Calculi in a Complex Biliary Tract Using Endourologic Equipment

Lithotripsy of Biliary Calculi in a Complex Biliary Tract Using Endourologic Equipment