Cardiova~c lntervent Radiol (1990) 13:240.-244
CardioVascular and Interventional Radiology ',L Springer-VeMag New York Inc. 1990
Biliary Duct Stones: Percutaneous Transhepatic Removal Kenneth R. Stokes and blelvin E. Clouse I)epartmcnl of Diagnostic Radioh)gy. New Enghmd Deacone~,~, Hospital and Harvard Medical School. Boston. Massachusetts. USA
Abstract. Percutaneous transhepatic removal of c o m m o n bile duct stones was performed 57 times in 53 patients with a success rate of 93%. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and papillotomy. A modified Dormia basket was inserted through a percutaneous transhepatic approach and the stones or fragments were advanced into the duodenum. Monooctanoin (26 patients) or methyl tertiary butyl ether (4 patients) was infused to reduce stone size or remove residual debris. The av'erage time for complete stone removal was 8.5 days. Morbidity was 12r and mortality was 4 ~ . results which compare favorably with those of surgery. Key words: Bile d u c t s - - S t o n e culi--lnterventional procedures .
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extraction--Cal.
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The preferred method for biliary stone removal without the presence of a T-tube is endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, which is effective in up to 90% of patients [1]. If stones are larger than 8 mm in diameter, however, removal by ERCP can be difficult, and if it is unsuccessful, we have routinely performed percutaneous transhepatic stone removal instead of surgery [2-41. This is especially true in patients following c h o l e c y s t e c t o m y and in elderly or debilitated patients among w h o m surgical morbidity and mortality rates are quite high. Patients and Methods Fifty-three patients (ages 43-94 years; mean 75 years) underwent pert.'ut:lneous transhepatic ~,tone femora] 57 times for common bile duct and intrahepatic biliar.,, stone:~. The pJocedure :',as perAddress reprinl rcq,e.~'ts to." Kenneth R. Stc, kcs, M.D.. New England Deacone.~s Hospital. Deparm,ent of Radioh.)gy. IS5 Pilgrim Road, Boqon. MA 02215. USA
formed twice in I patient and three times in a second patient 9,vithin a 2-year period because o f recurrent stone t~rmation. Patients presented with ob'dructive jaundice, biliary colic, or cholangitis. Percutaneous removal was per-formed in 23 patients because o f failure o f ERCP. patient refusal o f a second ERCP examination, or patient preference. Ten patients had undergone chuledochojejunostomy. Surgery "eva,,relatively or absolutely contraindicated in 23 patients due to the patient's advanced age. poor health, severe cardiopulmonary disease, obesity, or sepsis. Standard percutaneous transhepatic chohmgiography (PfC) u.,,ing a 22-gauge Chiba needle wits performed to delineate the biliary tree. m,ually through the right hepatic lobe. In the righl lobe, the first needle puncture usua[ly entered a duct that wit.-, too central or that was directed inapprc, pri:,tely for further manipulation. Using either a 19-gauge sheath needle or a 21-gauge Chiba needle in conjunction ,aith an Accustick Introducer System (Meditech. Watertown. MA). a laterally oriented duct was then entered as peripherally as possible. When a [eft hepatic duct ,,,,as u.,,ed, the inl;zri,.)r segmental duct of the left lateral h)be wa-, entered peripheral[.,,. If the patiern had cholangitis or was otherwise ill or" if the biliary catheterizati,.m had been difficult, an external biliary drain v, as placed in the common bile duct. Further manipulation wa.~ perforn:cd I-2 days later. If'the initial drainage ,.',us ~ell toler'lted and the patient was at low risk, further m:,nipulation ',va> peHormed at thi.,, initial time. Following dilatati,.:,n ,.)f the tran:.,hepatic tract, an 8 French 20-cm Teflon sheath with a one-way check-flo'a, valve (Check-rio lntrodt,cer Set. Cook, Bloomington. [N I ,,va~, advanced into the comm,.)[l bile duct. A smaller 7 French sheath was then inserted into the check-flow sheath and advanced over a guidewire through The ampulla .of Vater. We have found the Terumo guidewire (Meditech Inc.. Watertown. MA) most helpful in crossing the ampt, lla. With the 7 French sheath in the duodenum, the guidewire was removed. A modified Dormia basket ICook) was inserted so that its flexible tip was in the duodenum .'rod the basket wa~ positioned in the common bile duct (Fig. I). Our Dormia basket has been modified by the addition of a 3 - c m flexible guidewire tip 15!. With retraction of the sheath, the basket was ~apened preferably above the stone. The stone ,,,,a~, then snared in the basket and trapped within it by advancing both sheaths. If possible, the stone was then passed throt,gh the ampulkt by advancing the entire system its a unit. By retracting the basket, the stone was then crushed in the duodenum. Stones larger than 1.5 cm in diameter were often crushed in the c o m m o n bile duct and each fragment ,.'...as then ~,nared and advanced through the ampulla (Fig. 2). Very hard stone~ that were difficult to fragment alv, ays responded to slow steady pressure on the basket applied for tip to 10 rain. In 5 patients, addili,.)nal stones in the left hepalic duct were removed by pa>,sing a sheath fiom Ihe righl biliar?, tree into the
K.R. Stokes and M.E. Clouse: Biliary Duct Stones A
2~tl
B t,a:'
-etl
,"'""~ '
-:7
\
..'
r~
CardioVascular and Interventional Radiology ',L Springer-VeMag New York Inc. 1990
Biliary Duct Stones: Percutaneous Transhepatic Removal Kenneth R. Stokes and blelvin E. Clouse I)epartmcnl of Diagnostic Radioh)gy. New Enghmd Deacone~,~, Hospital and Harvard Medical School. Boston. Massachusetts. USA
Abstract. Percutaneous transhepatic removal of c o m m o n bile duct stones was performed 57 times in 53 patients with a success rate of 93%. All patients had contraindications to surgery or had undergone unsuccessful attempts at endoscopic retrograde cholangiopancreatography and papillotomy. A modified Dormia basket was inserted through a percutaneous transhepatic approach and the stones or fragments were advanced into the duodenum. Monooctanoin (26 patients) or methyl tertiary butyl ether (4 patients) was infused to reduce stone size or remove residual debris. The av'erage time for complete stone removal was 8.5 days. Morbidity was 12r and mortality was 4 ~ . results which compare favorably with those of surgery. Key words: Bile d u c t s - - S t o n e culi--lnterventional procedures .
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extraction--Cal.
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The preferred method for biliary stone removal without the presence of a T-tube is endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy, which is effective in up to 90% of patients [1]. If stones are larger than 8 mm in diameter, however, removal by ERCP can be difficult, and if it is unsuccessful, we have routinely performed percutaneous transhepatic stone removal instead of surgery [2-41. This is especially true in patients following c h o l e c y s t e c t o m y and in elderly or debilitated patients among w h o m surgical morbidity and mortality rates are quite high. Patients and Methods Fifty-three patients (ages 43-94 years; mean 75 years) underwent pert.'ut:lneous transhepatic ~,tone femora] 57 times for common bile duct and intrahepatic biliar.,, stone:~. The pJocedure :',as perAddress reprinl rcq,e.~'ts to." Kenneth R. Stc, kcs, M.D.. New England Deacone.~s Hospital. Deparm,ent of Radioh.)gy. IS5 Pilgrim Road, Boqon. MA 02215. USA
formed twice in I patient and three times in a second patient 9,vithin a 2-year period because o f recurrent stone t~rmation. Patients presented with ob'dructive jaundice, biliary colic, or cholangitis. Percutaneous removal was per-formed in 23 patients because o f failure o f ERCP. patient refusal o f a second ERCP examination, or patient preference. Ten patients had undergone chuledochojejunostomy. Surgery "eva,,relatively or absolutely contraindicated in 23 patients due to the patient's advanced age. poor health, severe cardiopulmonary disease, obesity, or sepsis. Standard percutaneous transhepatic chohmgiography (PfC) u.,,ing a 22-gauge Chiba needle wits performed to delineate the biliary tree. m,ually through the right hepatic lobe. In the righl lobe, the first needle puncture usua[ly entered a duct that wit.-, too central or that was directed inapprc, pri:,tely for further manipulation. Using either a 19-gauge sheath needle or a 21-gauge Chiba needle in conjunction ,aith an Accustick Introducer System (Meditech. Watertown. MA). a laterally oriented duct was then entered as peripherally as possible. When a [eft hepatic duct ,,,,as u.,,ed, the inl;zri,.)r segmental duct of the left lateral h)be wa-, entered peripheral[.,,. If the patiern had cholangitis or was otherwise ill or" if the biliary catheterizati,.m had been difficult, an external biliary drain v, as placed in the common bile duct. Further manipulation wa.~ perforn:cd I-2 days later. If'the initial drainage ,.',us ~ell toler'lted and the patient was at low risk, further m:,nipulation ',va> peHormed at thi.,, initial time. Following dilatati,.:,n ,.)f the tran:.,hepatic tract, an 8 French 20-cm Teflon sheath with a one-way check-flo'a, valve (Check-rio lntrodt,cer Set. Cook, Bloomington. [N I ,,va~, advanced into the comm,.)[l bile duct. A smaller 7 French sheath was then inserted into the check-flow sheath and advanced over a guidewire through The ampulla .of Vater. We have found the Terumo guidewire (Meditech Inc.. Watertown. MA) most helpful in crossing the ampt, lla. With the 7 French sheath in the duodenum, the guidewire was removed. A modified Dormia basket ICook) was inserted so that its flexible tip was in the duodenum .'rod the basket wa~ positioned in the common bile duct (Fig. I). Our Dormia basket has been modified by the addition of a 3 - c m flexible guidewire tip 15!. With retraction of the sheath, the basket was ~apened preferably above the stone. The stone ,,,,a~, then snared in the basket and trapped within it by advancing both sheaths. If possible, the stone was then passed throt,gh the ampulkt by advancing the entire system its a unit. By retracting the basket, the stone was then crushed in the duodenum. Stones larger than 1.5 cm in diameter were often crushed in the c o m m o n bile duct and each fragment ,.'...as then ~,nared and advanced through the ampulla (Fig. 2). Very hard stone~ that were difficult to fragment alv, ays responded to slow steady pressure on the basket applied for tip to 10 rain. In 5 patients, addili,.)nal stones in the left hepalic duct were removed by pa>,sing a sheath fiom Ihe righl biliar?, tree into the
K.R. Stokes and M.E. Clouse: Biliary Duct Stones A
2~tl
B t,a:'
-etl
,"'""~ '
-:7
\
..'
r~
