Using percutaneous transhepatic cholangioscopic lithotripsy for intrahepatic calculus in hostile abdomen

Background: Hepatolithiasis is a challenging condition to treat especially in patients with previous hepatobiliary surgery. Percutaneous Transhepatic Cholangioscopic Lithotripsy (PTCSL) is an attractive salvage option for the treatment of recurrent hepatolithiasis. We reviewed our experience using PTCSL in treating 4 patients with previous complex abdominal surgery. Methods: We studied the 4 patients who underwent PTCSL from October 2007 to July 2009. We reviewed the operative procedures, workflow of performing PTCSL in our institution and the outcome of the procedure. PTCSL was performed in our institution using 3 mm cholangioscope (Dornier MedTech (R)) and Holmium laser with setting at 0.8 J, 20 Hz and 16 W. This was performed through a Percutaneous Transhepatic Cholangio-catheter inserted by interventional radiologists. Results: There were 4 patients with a median age of 50(43-69) years. The median duration of the condition prior to PTCSL was 102(60-156) months. Three patients had recurrent pyogenic cholangitis (RPC) with recurrent intrahepatic stone. They all had prior complex hepatobiliary operations. The median duration of surgery was 130(125-180) min. There was minimal intra-operative blood loss. The first procedure was performed under local anaesthesia and sedation, however, with experience the subsequent 3 patients had the procedure performed under general anaesthesia. The median size of bile duct was 18 (15-20) mm prior to the procedure. The number of stones ranged from one to three with the largest size of stone comparable to the size of bile duct. The median follow up was 18(10-24) months. All patients were symptom free with neither stone recurrence or cholangitis at the last follow up. Conclusion: PTCSL is a feasible and an effective treatment method for patients with recurrent biliary stone following complex abdominal surgery as the success rates from open surgery and endoscopic procedures are limited. Excellent results can be expected with this minimally invasive technique. (C) 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.