Percutaneous Endoscopic Biliary Lithectomy: An Alternative to Endoscopic Retrograde Cholangiopancreatography and Cholecystectomy

Abstract

Introduction:

Choledocholithiasis is typically treated with endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy. Patients with prohibitive operative risk can undergo percutaneous transhepatic cholecystostomy (PTC) drain placement, which usually is a palliative procedure. ¹ These drains can be left in place indefinitely with periodic exchanges if definitive treatment is unfeasible. Surgical endoscopists can utilize the PTC drain tract to treat cholelithiasis and choledocholithiasis in these patients. Percutaneous endoscopic biliary lithectomy (PEBL) utilizes a disposable 10Fr choledochoscope with a therapeutic working channel that can accommodate various endoscopic tools and electrohydraulic (EHL) and laser lithotripsy systems. In this mini case series, we demonstrate the utility of PEBL in treating cholelithiasis and choledocholithiasis.

Materials and Methods:

Our first patient is a 62-year-old female with a history of pancreatic divisum complicated by multiple bouts of pancreatitis and DVT on anticoagulation who suffered a duodenal perforation during a previous ERCP necessitating Roux-en-Y reconstruction. She also underwent multiple small bowel resections and now suffers from short gut syndrome and is TPN-dependent. She presented with acute calculus cholecystitis, requiring PTC drain placement due to her altered foregut anatomy and medical comorbidities, followed by PEBL in the outpatient setting. Calculi within the gallbladder were extracted using tipless nitinol baskets, and attempts to navigate down the cystic duct were unsuccessful due to the duct’s small diameter. Post-procedure cholangiogram demonstrated no filling defects within the biliary system, and contrast flowed into the duodenum. The patient was discharged home after the procedure. The second case involves a medically and surgically complex 61-year-old male. His foregut anatomy was reconstructed as an infant, and in early adulthood, he underwent revision of his anatomy due to a bowel obstruction. The patient was unable to recall the details of either operation, and operative reports are unavailable. He presented with cholelithiasis and symptomatic choledocholithiasis. Two attempted ERCPs failed to identify the ampulla. Laparoscopic cholecystectomy was attempted and aborted due to severe adhesive disease. He then underwent PTC drain placement and three PEBL procedures in the outpatient setting. His first PEBL resulted in the basket extraction of calculi in the gallbladder and CBD. The second PEBL utilized EHL to fragment a calculus in the CBD. The third PEBL extracted some residual stone debris in the CBD. His drain was removed at the end of his third PEBL, and he was discharged home the same day.

Results:

The first patient returned to the emergency department one year after her PEBL procedure with acalculous cholecystitis secondary to an occluded cystic duct. She had a PTC drain placed and is currently undergoing evaluation for either surgical or endoscopic intervention. The second patient recovered uneventfully following his third PEBL procedure and has been symptom-free for 18 months.

Conclusions:

We demonstrate the utility of PEBL in treating cholelithiasis and choledocholithiasis in patients with prohibitive operative risk. PEBL can eliminate the need for long-term PTC drain and its associated morbidity. In patients with recurrent symptoms, replacement of a PTC drain can afford patients the opportunity for repeat endoscopic interventions or serve as a bridge to surgical intervention.

Disclosures:

Eric D. Moyer, MD—None. McKell Quattrone, MD—None. Samuel Zolin, MD—None. Eric M. Pauli, MD, FACS, FASGE—Speaking/teaching: Bard Davol, Medtronic, Ovesco. Consultant: Boston Scientific Corp., Actuated Biomedical, Inc., Baxter, Cook Biotech, Neptune Medical, Surgimatrix, CMR Surgical, Boehringer Laboratories, Allergan. Royalties: UpToDate, Inc., Springer. Financial Interests: IHC Inc, Contamination Source Identification, SIG Biomedical. Joshua Winder, MD, FACS—Consultant: Boston Scientific Corp.

Consents. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

Runtime of video:

09 mins 56 secs.