An Off-Road Trail of Laser lithotripsy

Background: Management of hepatolithiasis in status post-hepaticojejunostomy is a challenge due to the complex anatomy. SpyGlass-Direct visualization system has enabled to overcome this challenge by implementing percutaneous transhepatic biliary Laser lithotripsy (PTBLL) with a holmium: (YAG) Laser.

Case Report: A 16-year-old female presented with H/O of severe abdominal pain and fever. Significant past history being diagnosed with choledochal cyst—Type I in 2016, underwent open CDC excision + hepaticojejunostomy. In 2020, had obstructive Jaundice-multiple calculi in hepatic ducts and RHD were strictured. Underwent re-do laparotomy and strictureplasty. All the above procedures were done elsewhere.

At presentation to our hospital, lab reports showed mild elevation of cholestatic enzymes. MRCP showed moderate IHBRD, both right and left hepatic ducts measuring ~16 mm with hepatolithiasis, large stone at the confluence of right and left hepatic ducts measuring ~19 × 20 mm. Interventional Radiology team was involved. PTBD done, 8-Fr external drain was placed. Over existing PTBD, catheter was passed, serial dilatation of tract done. 12-Fr Flexor sheath positioned. SpyGlass Cholangioscope was introduced and multiple calculi seen within biliary ducts. Percutaneous transhepatic cholangioscopy–guided Laser lithotripsy of large intrahepatic stones was targeted and fragmented. Balloon dilatation of HJ site was done. Internal–external drain was placed.

Repeat MRCP showed no IHBRD/stones. After 6 weeks, PTC done showed tiny filling defects suggestive of stone fragments. PTBD tube was exchanged and external drain was closed. Presently patient on follow-up and is asymptomatic.

Conclusion: Percutaneous transhepatic biliary laser lithotripsy (PTBLL) can be considered as an alternative approach for hepatolithiasis in intricate cases that are not feasible by routine ERCP due to modified anatomy.

Publication History

Article published online:
22 April 2024