Percutaneous Transhepatic Cholangioscopic Laser Lithotripsy for Hepaticolithiasis in a Patient with Surgically Altered Biliary Anatomy

Background: Percutaneous transhepatic cholangioscopic laser lithotripsy (PTCLL) is a novel technique used for treating hepaticolithiasis in patients who are not amenable to endoscopic management. We present a case of hepaticolithiasis in a patient with surgically altered biliary anatomy who required a technically demanding laser lithotripsy via percutaneous route.

Method: A 53-year-old gentleman presented to the casualty with features of obstructive jaundice and cholangitis. He had undergone hepaticojejunostomy (HJ) after a complicated cholecystectomy, 13 years back. Imaging revealed stricture at the hepaticojejunostomy site with upstream biliary dilatation and a large calculus at the confluence of right and left hepatic ducts. Immediate percutaneous transhepatic biliary drainage was done to relieve cholangitis. After 5 days, a cholangioscope was introduced into the right hepatic duct through the percutaneous access and the calculus pulverized using Thulium laser. Cholangioscope was then maneuvered into left duct to pulverize the remaining calculus segment. A guidewire was passed into the left hepatic duct, and balloon sweep was done to bring the stone fragments into the common hepatic duct. The balloon was positioned in the right duct and fragments were pushed into the jejunum. Subsequent reverse occlusion cholangiogram showed complete clearance (Fig. 1) and the patient was discharged with a drain on Day 7. The drain was removed after doing a cholangiogram at 3 weeks follow-up.

Conclusion: Redo-surgery for HJ strictures and hepaticolithiasis carries a complication rate of up to 50%. An alternative is laser lithotripsy which is minimally invasive with reduced morbidity and mortality. In patients with surgically altered biliary anatomy, laser lithotripsy can be performed through percutaneous transhepatic route. An average of 5 sessions are usually required to clear hepaticolithiasis using PTCLL. By using balloon sweep method, we could achieve clearance with a single session, resulting in a short hospital stay and reduced morbidity to the patient.

Publication History

Article published online:
22 April 2024