Expanding Endourology for Biliary Stone Disease: The Efficacy of Intracorporeal Lithotripsy on Refractory Biliary Calculi

Abstract

Background and Purpose:

We evaluated the efficacy of ureteroscopic therapy (electrohydraulic lithotripsy [EHL] and intraductal laser lithotripsy [ILL]) in patients with challenging biliary stones secondary to anatomic variations resulting from a previous surgical procedure, including liver transplantation.

Patients and Methods:

A retrospective chart review was performed for all patients with previous surgical alteration of the gastrointestinal (GI) tract who underwent EHL or ILL via peroral or percutaneous access for choledocholithiasis by a single surgeon at our institution from 2000 to 2012. A database containing clinical and surgical variables was created, and long-term follow-up was conducted (3–138 months; median, 99 months).

Results:

Thirteen patients (51.7±20.0 years; M:F, 10:3) in whom endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTHC), or both failed were identified. Failure of ERCP/PTHC was because of inaccessibility of the calculi in all cases. Stone clearance was achieved in 12/13 (93%) patients; 8/12 (62%) after one procedure, and 4/12 (31%) after two procedures. One patient with biliary cast syndrome needed four interventions over 9 years. Major complications were low, with only one patient with hypotension and cholangitis that resolved with 24 hours of administration of intravenous fluids and antibiotics.

Conclusions:

Both endoscopic and percutaneous lithotripsies are effective treatments for refractory biliary calculi resulting from the post-surgical GI tract. Although a staged second procedure may be necessary in patients with significant stone burden, this is significantly better than extensive open surgery.

Introduction

Patients with a history of abdominal surgery involving the biliary tree are at increased risk for choledocholithiasis secondary to postoperative strictures, biliary tract infections, weight loss, decreased intestinal absorption, and impaired gallbladder motility.¹ The current standard for treatment of patients with choledocholithiasis is endoscopic retrograde cholangiopancreatography (ERCP) and is successful in approximately 85% of cases. In patients with Roux-en-Y anastomoses resulting from liver transplant or gastric bypass, however, the biliary tree may not be accessible with a standard endoscope, rendering ERCP unsuccessful.² Percutaneous transhepatic cholangiography (PTHC) may also be used, although it is more commonly performed to decompress and drain the obstructed biliary system for symptom relief. If both of these techniques fail, patients are faced with a complex laparoscopic or open biliary exploration. In a study of 18 postgastrectomy patients, morbidity for laparascopic biliary exploration was reported as 22.2%, although no mortalities occurred.³

Several alternatives have been suggested, including extracorporeal shockwave lithotripsy (SWL) and intracorporeal lithotripsy (with electrohydraulic [EHL], or laser lithotripsy [ILL]) under direct visualization. SWL is rarely used, because it is less effective than ILL in regard to both stone clearance rate and treatment duration.⁴ In terms of biliary access in the anatomically altered patient, two options exist for intracorporeal lithotripsy: Peroral cholangioscopy via a “mother-baby” scope system or, more commonly, a percutaneous transhepatic approach.

Both EHL and ILL are safe and effective for the management of urinary tract calculi, and a number of studies have demonstrated similar application in the biliary tree.^5

–11 ERCP failed in the majority of the patients in these studies secondary to large stones (>2 cm), and very little data are available regarding those patients with inaccessible calculi because of anatomically altered gastrointestinal (GI) tracts. In this study, we report a single surgeon's results from endourologic intracorporeal lithotripsy of biliary stones inaccessible via conventional techniques secondary to surgically altered GI anatomy.

Patients and Methods

With Institutional Review Board approval, clinical data were obtained for 13 consecutive patients who underwent intracorporeal lithotripsy secondary to failure of ERCP and/or PTHC between November 2000 and July 2013 by a single surgeon (SYN). A total of 20 procedures were performed on 10 men and 3 women (51.7±20.0 years). All patients had undergone a previous GI procedure, resulting in failure of previous stone removal because of altered anatomy and access (Table 1). The most common presentation was cholangitis (seven), followed by four with symptoms of cholestasis, one with pancreatitis, and one with elevated liver enzymes. Stone number and diameter were measured by an independent radiologist with a McKesson Enterprise Medical Imaging stand-alone picture archiving and communication system (San Francisco, CA) using available periprocedural imaging (magnetic resonance cholangiopancreatography [MRCP], ERCP, CT, cholangiography, or tube check). Volume was then calculated using the assumption of an ellipse (4/3π Χ L×W×H). Primary outcomes were stone-free rates (SFR) and complications.

Table 1.

Patient and Procedure Characteristics

ID	Sex	Age (y)	Previous surgery	Failed conventional procedure	EHL/ILL	Access	Total stone burden (cc)	Follow-up procedure(s) needed?
1	F	32	Complete excision of extrahepatic biliary tree, Roux-en-Y hepaticojejunostomy, cholecystectomy	PTHC	Laser	Percutaneous	9.4	No
2	M	18	Liver transplant	ERCP/PTHC	Laser	Percutaneous	3.5	No
3	F	28	Laparoscopic common bile duct exploration, cholecystectomy	ERCP/PTHC	Laser	Percutaneous	4.19	No
4	M	54	Liver transplant	ERCP/PTHC	Laser	Percutaneous	9.11	No
5	F	75	Liver transplant, cholecystectomy	ERCP/PTHC	EHL	Percutaneous	27.7	Yes, EHL ×1
6	M	40	Whipple, colostomy, cholecystectomy	PTHC	EHL	Percutaneous	9.9	No
7	M	60	Liver transplant	ERCP/PTHC	EHL	Percutaneous	N/A	No
8	M	52	Liver transplant, open repair of common bile duct	PTHC	EHL	Percutaneous	9.1	Yes, EHL ×1
9	M	88	Pancreatico-duodenectomy, cholecystectomy	ERCP/PTHC	EHL	Percutaneous	5.2	Yes, EHL ×1
10	M	43	Liver Transplant	ERCP/PTHC	EHL	Peroral	116.1	Yes, laser ×1, EHL ×2^a
11	M	48	Liver transplant, Roux-en-Y choledochojejunostomy for biliary stricture	PTHC	EHL	Percutaneous	1.2	No
12	M	60	Liver transplant	ERCP	EHL	Peroral	1.1	Yes, EHL ×1
13	M	74	Roux-en-Y gastrectomy	ERCP/PTHC	Laser	Percutaneous	9.9	No

Patient with biliary cast syndrome.

EHL=electrohydraulic lithotripsy; ILL=intraductal laser lithotripsy; PTHC=percutaneous transhepatic cholangiography; ERCP=endoscopic retrograde cholangiopancreatography.

Surgical technique

Eleven of the 13 initial cases were performed percutaneously through a previously established PTHC tract, and 2 used a mother-baby endoscopic system via collaboration with a gastroenterologist. Appropriate antibiotics were administered preoperatively. EHL was used in eight cases, and ILL was used in five. From 2006 forward, the holmium laser was used because it ultimately replaced EHL as the primary urologic lithotripter at our institution. Percutaneous procedures necessitated general anesthesia, and peroral procedures were performed under conscious sedation.

Percutaneous approach

All patients undergoing the percutaneous approach had an existing percutaneous hepatic drain. Using standard techniques, the tract was dilated to 10F to 14F, with placement of an access sheath. The 7F flexible ureteroscope was advanced to the stone(s). Fragmentation was achieved using EHL at 10% to 50% power with mild irrigation, or 200/270 micron holmium laser fiber at 8 Hz and 0.8 J. Stone fragments were flushed antegrade into the duodenum, or retrograde out of the access sheath. Cholangiography was performed at the conclusion of the procedure to evaluate stone clearance and, when necessary, Fogarty balloon sweeps were used to clear residual stone fragments. The percutaneous hepatic drain was then replaced, and cholangiograms were obtained between 2 and 20 days postoperatively to reevaluate stone clearance.

Peroral approach

In the two patients who had not undergone previous PTHC, collaboration with a GI endoscopist using a mother-baby system was used to obtain access to the biliary system. Both cases were performed before 2006, so a 1.7F EHL probe was directed through the mother endoscope to the location of the stone and fragmentation accomplished using the aforementioned power settings. Basket and balloon sweeps were then performed by the endoscopist to clear any remaining fragments.

Results

Of 13 patients with surgically altered GI anatomy, previous ERCP alone failed in 1, PTHC alone failed in 4, and both ERCP and PTHC failed in 8 before our intervention (Table 1). The most common previous surgical procedure was liver transplant with Roux-en-Y anastomoses (8/13, 61.5%). Of the eight, indication for transplant included: Cirrhosis secondary to hepatitis C and alcohol abuse (three), idiopathic cirrhosis (two), α-1-antitrypsin deficiency (one), biliary atresia at birth (one), and primary biliary cirrhosis (one). In the entire cohort, the most common etiology of stones was postoperative biliary strictures (eight), with recurrent infection, cholestasis, and ischemia playing a role in the other five patients.

Mean number of stones was 2.8±2.2 with mean stone volume of 17.2±30.5 cc (range 1.1–116.1 cc). One patient (ID #7) did not have periprocedural imaging available, and stone number and volume were unknown. Stone location was equally distributed between the common bile duct (7/13) and intrahepatic tract (7/13), with one patient having stones in both locations. In regard to stone clearance, 93% (12/13) were rendered stone free after 1.33±0.47 procedures, with 62% stone free after a single procedure. Follow-up of 3 to 138 months (median: 99 months) revealed no patients with de novo strictures postlithotripsy.

One patient with an initial stone burden of 116.1 cc and biliary cast syndrome needed four intracorporeal lithotripsies over 9 years. Postoperative cholangitis and hypotension occurred after this patient's second procedure, a transhepatic EHL, and resolved after 24 hours of intensive care unit treatment with intravenous fluids and antibiotics. This patient eventually needed a repeat orthotopic liver transplant secondary to hepatic artery thrombosis with ischemic damage to the bile duct and liver parenchyma. Two patients experienced low-grade fever after their initial successful procedure, but each had resolution of fever within 24 hours without additional management. Of the 20 total procedures performed, no cases of postoperative pancreatitis were observed.

Discussion

Standard methods of stone removal such as ERCP or PTHC frequently fail because of restricted access to the biliary system in patients with previous surgical alteration of the GI tract who present with biliary calculi. Our findings suggest refractory stones in this subset of patients are amenable to treatment with intracorporeal lithotripsy via a percutaneous or peroral approach with a low rate of serious complications.

Ponsky and associates¹⁰ were one of the first groups to discuss the application of contemporary urologic techniques in the pancreaticobiliary tree and reported a 60% SFR after one procedure for five patients who were treated with percutaneous transhepatic intracorporeal lithotripsies. Two of the five patients underwent a second-look percutaneous procedure and were only then rendered stone free, resulting in a final SFR of 100%.¹⁰ Schatloff and colleagues¹¹ treated 14 patients with refractory biliary stones using percutaneous transhepatic ILL, of which 10 had previous surgical alteration of the GI tract. They reported 12/14 (85.7%) to be stone free after a single procedure, with 3/14 (21.4%) experiencing postoperative cholangitis.⁸ Healy and coworkers noted a SFR of 100% in 5 patients with previous surgical alteration after a single percutaneous ILL.¹¹

Hazey and colleagues⁷ reported a final SFR of 100% with an average of 1.6 percutaneous laser treatments (61.50% SFR after a single treatment) in a cohort of 13 patients; however, the exact number with previous surgical alteration was not reported. Ray and associates¹² reported a SFR of 76.2% in a cohort of 19 patients treated by percutaneous ILL with supportive use of EHL and ultrasound.¹² They note that some patients were referred secondary to “unfavorable anatomy for ERCP,” but the exact number was not documented. These studies reporting SFR in patients with refractory biliary calculi and percutaneous endoscopic fragmentation are summarized in Table 2.

Table 2.

Stone-Free Rates in Patients with Refractory Biliary Calculi

Author (year)	# Patients	Access	Altered anatomy?	Fragmentation	SFR ^a
Ponsky et al. (2001)¹⁰	5	Percutaneous	N	EHL/ILL	60%
Schatloff et al. (2009)⁸	14	Percutaneous	Y, 10/14	ILL	86%
Healy et al. (2009)¹¹	5	Percutaneous	Y, 5/5	ILL	100%
Hazey et al. (2007)⁷	13	Percutaneous	Unknown	ILL	61.50%
Ray et al. (2009)¹²	19	Percutaneous	Unknown	EHL/ILL	76.20%
Current series	13	Perc x 11, Peroral x2	Y, 13/13	EHL/ILL	62%

After one procedure.

SFR=stone-free rate; EHL=electrohydraulic lithotripsy; ILL=intraductal laser lithotripsy.

Regarding the peroral approach, SFR are reported to be between 77% and 97% using EHL or ILL with a combination of mother-baby technique and the Spyglass single operator system, although no studies document specific treatment of patients with altered anatomy.^6,9 In patients without current percutaneous hepatobiliary access, endoscopic approach is preferred to avoid the additional invasive step of creating and dilating a tract. The dual-endoscopy approach, however, has multiple limitations including delicate instrumentation and impaired maneuverability.⁹

To our knowledge, this is the first series to specifically assess treatment of biliary stones in patients with surgically altered GI anatomy. The interdisciplinary approach with interventional radiologists, gastroenterologists, and urologists provides a unique opportunity for minimally invasive intervention with decreased morbidity vs a standard open operation. Ultimately, the goal is stone clearance and symptomatic relief, with avoidance of long-term requirement for a percutaneous biliary catheter. Although reporting on a specific subset of patients, our findings of a SFR of 93% (1.33±0.47 procedures) is consistent with the findings of other series addressing similar patient cohorts.^4,8,11,12 Our major complication rate of 5% (1/20) is comparable to that of previous studies, as well as the 5.3% rate for standard ERCP reported in a recent large series.¹³

The limitations of our series include its retrospective nature, the transition of EHL to ILL over the course of the study, uneven distribution between percutaneous vs peroral access, and the small number of patients. In summary, multiple surgical modalities are available for patients with altered anatomy and biliary stones. The advent of the flexible ureteroscope with a narrow diameter permits access to an intricate and complicated biliary tree and minimizes bleeding by use of a smaller access sheath. Management is dictated by access to the hepatobiliary tree, surgeon experience, and preoperative functional status of the patient.

The emergence of the single operator peroral Spyglass scope, an ultrathin, four-way deflectable, multichannel system may be a solution for those patients without percutaneous access.¹⁴ Further studies are needed, however, to evaluate its performance in patients with unique biliary anatomy.

Conclusions

In patients with biliary stones and surgically altered GI anatomy, intracorporeal lithotripsy using endourologic techniques produce high SFRs with minimal complications. Although a staged secondary procedure may be needed for large stone burdens, these techniques are attractive alternatives to open stone removal with high morbidity.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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