Published online Apr 16, 2019. doi: 10.4253/wjge.v11.i4.298
Peer-review started: February 20, 2019
First decision: February 26, 2019
Revised: March 15, 2019
Accepted: March 26, 2019
Article in press: March 26, 2019
Published online: April 16, 2019
Endoscopic retrograde cholangiopancreatography (ERCP) is preferred for managing biliary obstruction in patients with bilio-enteric anastomotic strictures (BEAS) and calculi. In patients whose duodenal anatomy is altered following upper gastrointestinal (UGI) tract surgery, ERCP is technically challenging because the biliary tree becomes difficult to access by per-oral endoscopy. Advanced endoscopic therapies like balloon-enteroscopy or rendevous-ERCP may be considered but are not always feasible. Biliary sepsis and comorbidities may also make these patients poor candidates for surgical management of their biliary obstruction.
We present two 70-year-old caucasian patients admitted as emergencies with obstructive cholangitis. Both patients had BEAS associated with calculi that were predominantly extrahepatic in Patient 1 and intrahepatic in Patient 2. Both patients were unsuitable for conventional ERCP due to surgically-altered UGl anatomy. Emergency biliary drainage was by percutaneous transhepatic cholangiography (PTC) in both cases and after 6-weeks’ maturation, PTC tracts were dilated to perform percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) for duct clearance. BEAS were firstly dilated fluoroscopically, and then biliary stones were flushed into the small bowel or basket-retrieved under visualization provided by the percutaneously-inserted video cholangioscope. Lithotripsy was used to fragment impacted calculi, also under visualization by video cholangioscopy. Satisfactory duct clearance was achieved in Patient 1 after one PTCSL procedure, but Patient 2 required a further procedure to clear persisting intrahepatic calculi. Ultimately both patients had successful stone clearance confirmed by check cholangiograms.
PTCSL offers a pragmatic, feasible and safe method for biliary tract clearance when neither ERCP nor surgical exploration is suitable.
Core tip: The purpose of this case report is to highlight the feasibility of percutaneous transhepatic cholangioscopy and lithotripsy (PTCSL) as therapy for biliary obstruction in patients with surgically altered anatomy which makes them unsuitable for conventional endoscopic retrograde cholangiopancreatography. Percutaneous transhepatic cholangiography used for emergency biliary drainage provides the access required for PTCSL, so it is reasonable to consider PTCSL in such patients. PTCSL attractively combines radiological and endoscopic techniques already established in most Hepato-Pancreato-Biliary units. Advanced endoscopic options are not widely available, and surgical options are limited as such patients are poor surgical candidates. We review the literature to compare our cases to previously reported cases of PTCSL.