Percutaneous Biliary stone removal

Percutaneous biliary stone removal, also known as percutaneous transhepatic cholangioscopy (PTCS), is a minimally invasive procedure used to remove bile duct stones that are difficult to manage through conventional endoscopic techniques. 

Indications for Percutaneous Biliary Stone Removal

1. Complex Biliary Stones: Stones located in the intrahepatic bile ducts, hepatic ducts, or proximal common bile duct that cannot be accessed or removed with standard endoscopic retrograde cholangiopancreatography (ERCP).
2. Failed ERCP: Patients with failed or incomplete stone removal during ERCP due to anatomical challenges, strictures, or large impacted stones.
3. High-Risk Patients: Patients with significant comorbidities or high surgical risk who are not suitable candidates for surgical bile duct exploration.

Pre-procedure Preparation

1. Patient Assessment:
   • Comprehensive evaluation of the patient’s medical history, symptoms, laboratory tests (including liver function tests and inflammatory markers), imaging studies (such as ultrasound, CT scan, MRI), and coagulation profile.
   • Assessment of the location, size, number, and composition of biliary stones.
2. Imaging Studies:
   • Pre-procedure imaging studies, such as abdominal ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic ultrasound (EUS), to visualize the bile duct anatomy and stone characteristics.
3. Informed Consent:
   • Explanation of the percutaneous biliary stone removal procedure, its purpose, potential risks (such as bleeding, infection, bile duct injury, pancreatitis), benefits, and alternatives. Informed consent is obtained.

Procedure Steps

1. Patient Positioning:
   • The patient is typically positioned lying down on the procedure table, with the right upper quadrant of the abdomen exposed.
2. Local Anesthesia:
   • Local anesthesia is administered at the puncture site (usually in the right upper quadrant) under ultrasound or fluoroscopic guidance.
3. Percutaneous Access:
   • A needle is inserted percutaneously through the skin and into the liver parenchyma under real-time ultrasound or fluoroscopic guidance.
   • A guide wire is then advanced through the needle and into the bile ducts, navigating toward the location of the biliary stones.
4. Dilatation and Cholangioscopy:
   • Over the guide wire, a series of dilators are inserted to create a tract for the cholangioscope.
   • A cholangioscope (thin, flexible tube with a camera at the tip) is advanced through the dilated tract and into the bile ducts, allowing direct visualization of the stones.
5. Stone Removal:
   • Endoscopic tools, such as stone retrieval baskets, balloons, or lithotripsy devices, are used through the cholangioscope to grasp, fragment, or extract the biliary stones.
   • Multiple techniques may be employed, including mechanical lithotripsy, electrohydraulic lithotripsy (EHL), or laser lithotripsy, depending on the size and composition of the stones.
6. Stent Placement (if needed):
   • In cases of biliary strictures, residual stones, or to maintain duct patency, a biliary stent may be placed through the cholangioscope after stone removal.
7. Closure and Post-procedure Care:
   • Once stone removal is complete, the cholangioscope is removed, and pressure is applied to the puncture site to achieve hemostasis.
   • Close monitoring of the patient’s vital signs, abdominal symptoms, and post-procedure complications (such as pancreatitis, bile leakage) is conducted.

Benefits and Clinical Outcomes

• Complete Stone Clearance: Percutaneous biliary stone removal allows direct visualization and effective removal of complex biliary stones that are challenging to manage with standard ERCP techniques.
• Reduced Complications: Minimally invasive approach compared to surgical bile duct exploration, leading to reduced risks of complications and shorter recovery time.
• Improved Bile Duct Patency: Removal of obstructing stones improves bile flow, reduces the risk of recurrent biliary obstruction, cholangitis, and associated complications.
• Potential for Stent Placement: Concurrent placement of biliary stents during the procedure can help maintain duct patency and prevent stricture recurrence.

Risks and Considerations

• Bleeding: Risk of bleeding at the puncture site or within the liver parenchyma during the procedure.
• Infection: Potential for catheter-related infections, although rare with proper aseptic techniques.
• Bile Duct Injury: Risk of bile duct injury or perforation during stone removal, particularly in cases of severe strictures or complex anatomy.
• Post-procedure Complications: Possibility of pancreatitis, bile leakage, or recurrent stone formation post-procedure, requiring close monitoring and management.

Post-procedure Care

1. Monitoring:
   • Close monitoring of the patient’s vital signs, abdominal symptoms, and drainage output (if a drain is placed) post-procedure.
   • Observation for signs of infection, pancreatitis, bile leakage, or other complications.
2. Antibiotics (if needed):
   • Prophylactic or therapeutic antibiotics may be prescribed based on the patient’s clinical condition, risk factors, and institutional guidelines.
3. Follow-up Imaging:
   • Follow-up imaging studies (such as abdominal ultrasound, CT scan, or MRCP) may be scheduled to assess stone clearance, biliary duct patency, and the need for further interventions or stent removal.

Conclusion

Percutaneous biliary stone removal (PTCS) is a valuable minimally invasive procedure for managing complex biliary stones that cannot be adequately addressed with standard endoscopic techniques. Close collaboration between interventional radiologists, gastroenterologists, and hepatobiliary specialists is essential for the successful planning, execution, and post-procedure care of PTCS procedures. Regular monitoring, follow-up imaging, and adherence to treatment strategies are crucial for optimizing outcomes and preventing complications in patients undergoing percutaneous biliary stone removal.