Kyler Kozacek, DO1, Lee Rousslang, MD1, J Matthew Meadows, MD1, Pedro Manibusan, Jr., DO2; 1Tripler Army Medical Center, Honolulu, HI; 2Tripler Army Medical Center, Mililani, HI
Introduction: ERCP is the gold standard to treat choledocolithiasis, though there are situations where ERCP is unsuccessful and alternative treatments are necessary. Percutaneous transhepatic choledoscopy (PTCS) is a safe, minimally invasive option performed by interventional radiology (IR) that can avoid more invasive treatments like hepatic resection.
Methods: A 45-year-old man sustained a traumatic liver laceration and bile duct injury during a military deployment in 2005. In 2011 he presented with right upper quadrant pain and was found to have cholangitis and gallstone pancreatitis due to an isolated segment of biliary ectasia and retained biliary stones in segment 7. He underwent open cholecystectomy with bile duct exploration and t-tube placement, but had recurring choledocolithiasis and retained intrahepatic stones in 2013, 2017, and 2019. ERCP sphincterotomy was performed to treat the choledocholithiasis, but was unable to localize the isolated segment of retained stones (Figure 1). The patient ultimately underwent percutaneous transhepatic cholangiography with biliary drain placement by an IR. MRI revealed a persistent segment of isolated biliary ectasia and retained biliary stones complicated by pancreatitis, prompting referral to our tertiary care center for evaluation. Cholangiogram revealed the isolated segment and a variant right hepatic duct arising from the main left hepatic duct. The drain was withdrawn and after repeat ERCP was performed without success, decision was made to perform PTCS. A 9.5-French LithoVue Single-use Digital Flexible ureteroscope (Boston Scientific, Marlborough, MA) was advanced into the liver via the established percutaneous access tract (Figure 2). The abnormal segment was identified and the retained stones were either extracted with a 2.4 French Zero-tip Nitinol Retrieval basket (Boston Scientific, Marlborough, MA) (Figure 3) or fragmented and flushed into the duodenum. When all stones were removed, an internal/external biliary drain was left in place and patient has been without further complications since. Discussion: This is the first reported case of PTCS with basket extraction to treat recurrent cholangitis from chronic biliary ectasia and retained biliary stones from a traumatic liver laceration. PTCS is well recognized as a safe and effective treatment for obstructing biliary stones not amenable to ERCP or hepatic resection. It can be safely performed through existing percutaneous access with small-caliber endoscopes with a high success rate.
Figure 1: ERCP cholangiogram demonstrates a right hepatic bile duct filling defect (arrow), following sphincterotomy to treat a recurrent episode of choledocolithiasis.
Figure 2: Intraprocedural fluoroscopic image of the liver demonstrates the entry of a flexible ureteroscope into the confluence of the right and left hepatic ducts (arrow).
Figure 3: Direct visualization of the biliary stones through ureteroscope with subsequent manual extraction of the stones using a 2.4 French Zero-tip Nitinol Retrieval basket.
Disclosures: Kyler Kozacek indicated no relevant financial relationships. Lee Rousslang indicated no relevant financial relationships. J Matthew Meadows indicated no relevant financial relationships. Pedro Manibusan indicated no relevant financial relationships.