Percutaneous endoscopic biliary exploration in complex biliary stone disease: Case series study

Abstract

Background and aim: Patients with complex biliary stone disease are challenging to treat. We present our experience using urological interventions to treat challenging biliary stones. Methods: Fifteen patients with biliary calculi underwent 21 interventions using either extracorporeal shock wave lithotripsy (ESWL), percutaneous transhepatic choledochoscopy, percutaneous transcystic choledochoscopy, or a combination of these. Results: Most patients were elderly (median age, 60 years). The male-to-female ratio was higher than the norm for biliary stones (1:1.4). The most common reasons for failure of conventional endoscopic retrograde cholangiopancreatography (ERCP) were high American Society of Anesthesia (ASA) score (8 patients 53%), technical failure of ERCP (4 patients, 27%), previous Roux-en-Y gastric bypass (two patients, 13%), and post-common bile duct (CBD) injury with T-tube insertion (one patient, 7%). The stone sites were the CBD, gallbladder, and intrahepatic bile duct in nine (60%), three (20%), and three (20%) patients, respectively. All patients underwent minimally invasive interventions. This included ESWL in seven cases and endoscopic laser lithotripsy and stone manipulation through an access tube in eight patients (transhepatic in four patients, transcholecystic in three patients, and using a T-tube in one patient). Complete stone clearance was achieved in 12 patients (80%), whereas four patients required a second session and one patient required a third. The remaining three patients, two had residual asymptomatic debris and one failed procedure. Conclusions: Complicated and high-risk patients with biliary stones could be managed with minimally invasive intervention without subjecting them to a major risky procedure.