Solved on SIR Connect

Biliary stone interventions

Original post, lightly edited for flow: bit.ly/3LEOqY4

I have a patient who presented with choledocholithiasis and sepsis. Due to lack of endoscopic retrograde cholangiopancreatography (ERCP) at my hospital, IR was consulted for percutaneous biliary drainage. I placed an internal-external drainage catheter. The patient was then sent out for ERCP and stone extraction; however, when he returned for removal a few weeks later, he had residual common bile duct (CBD) stones. The patient has not been able to see a GI for repeat ERCP, and he is frustrated and demanding tube removal. I explained the risks of removing the tube with stones still in place, but he’s pretty insistent. What would you do? 

Please elaborate on the specific patient background and presentation in this case.

Vijay Jaswani, MD: Patient is a 72 y/o who presented with epigastric pain, nausea and vomiting. A CT of the abdomen with IV contrast showed dilated intrahepatic ducts and dilated common bile duct to 12 mm. Patient was febrile, tachycardic and had elevated total bilirubin to 6.8. MRI/MRCP showed a distended gallbladder with innumerable calculi and multiple calculi obstructing the distal common bile duct. Given the patient’s sepsis and lack of ERCP capabilities at our institution, the patient was started on IV antibiotics and IR was consulted for urgent percutaneous biliary drainage and a drainage catheter was placed.

Two months later, the patient returned for a drain study to evaluate possible removal. An over-the-wire cholangiogram showed multiple filling defects in the common bile duct consistent with retained vs. new stones. Per discussion with the endoscopist, the postprocedure cholangiogram did not show these stones. However, visualization was limited secondary to presence of the biliary drainage catheter, which was not removed during the procedure. 

What are the different types of biliary interventions that IRs can offer?

VJ: IRs can offer multiple biliary interventions:

  • Percutaneous cholecystostomy (calculous or acalculous cholecystitis, patient is a nonsurgical candidate)
  • Percutaneous biliary drainage (PTBD) with placement of external or internal-external biliary drain (septic biliary obstruction/cholangitis, malignant biliary obstruction)
  • Percutaneous biliary stenting (malignant biliary obstruction)
  • Percutaneous biliary stone extraction

When placing a PTBD when do you consider internalization either via external/internal biliary drain or stenting? What specific methods, approach or techniques do you find useful in performing these cases?

VJ: Internalization is always preferred as it minimizes electrolyte and fluid imbalances potentially caused by external biliary drainage and increases patient comfort due to ability to cap or eliminate external drainage bag. In terms of approach, after a suitable target is identified on ultrasound, a 21- or 22-gauge needle is inserted, and a careful injection of contrast is performed in two projections to identify the bile ducts. Once access is obtained, an 0.018-in wire is advanced into the bile ducts, and a triaxial set can be used to help establish a working 0.038-in wire into the bile ducts/small bowel. As a helpful tip, it is often useful to access nondilated biliary systems with assistance of a guidewire. I also typically cross malignant obstructions with an angled catheter and a hydrophilic wire, after which an 8- to 10-French drain is placed under moderate sedation or anesthesia, as it’s typically painful for the patient. Once bilirubin is normalized and the patient can tolerate a capped drain without pain or fever, an internal biliary stent can then be placed.

In general, for patients with biliary drains, how do you follow up with them and when do you decide to remove the drain?  

VJ: After 4–6 weeks, the patient is brought back to IR for a tube study. For percutaneous cholecystostomy, the tube can be removed after confirming resolution of cystic duct obstruction. For internal-external biliary drains, these drains are typically either routinely exchanged every 2–3 months or converted to internal biliary stents.

What specifically prompted you to reach out regarding this case/topic?

VJ: Neither the interventional gastroenterologist nor another gastroenterologist had been able to take the patient back for repeat ERCP yet, and he was understandably frustrated. I explained the risks of removing the tube with stones still in place. However, the patient still wanted the tube removed.

In medical facilities without access to endoscopists and ERCP, what tools and techniques do IR physicians have to clear CBD stones?

VJ: It is possible to upsize the access, place a large sheath and balloon dilate the sphincter of Oddi, followed by pushing the stones through with a balloon. This is performed via percutaneous cholangioscopy and can also be used to directly visualize and treat the stones.

What post or posts were most valuable to you and why?

VJ: The post by Karen T. Brown, MD, FSIR, recommending pushing the stones through was most attractive because it could potentially solve the patient’s problem without relying on another specialty and we already had the tools to accomplish this. The post by R. Torrance Andrews, MD, FSIR, regarding respecting the patient’s choice to have the drain removed was also useful because the patient was very adamant in this case, and we must balance medical indications with patient autonomy.

Will you, or have you, changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering.

VJ: We were thinking of introducing a cholecystoscope system—however, we recently got interventional gastroenterology at our institution, so it makes cases like this easier to perform in conjunction with our gastroenterology colleagues.

Additional commentary

Approximately 200,000 people a year in the United States are treated for acute cholecystitis (AC).1 It has also been noted that approximately 13.7% of patients with acute cholecystitis have choledocholithiasis, which can lead to conditions such as cholangitis and pancreatitis.2 The well-known standard of care for patients with AC is laparoscopic cholecystectomy. Patients with AC and clinically high probability of choledocholithiasis will often first undergo ERCP or, alternatively, stable patients can undergo cholecystectomy with intraoperative cholangiogram and intervention if required.3 Often IRs become involved in the care of patients with AC and biliary obstruction when they are deemed too sick for surgery, ERCP has failed, is not available, or is not feasible due to postsurgical anatomy.4 In these situations IR physicians are often tasked with placing a cholecystostomy tube for AC, or to decompress the biliary system with PTBD. In patients with choledocholithiasis or cholelithiasis who are never surgical candidates, it can be beneficial for IR physicians to have the toolset and

capability to perform percutaneous stone extraction.

Multiple techniques can be deployed in the setting of both cholelithiasis and choledocholithiasis that have been shown to be both safe and effective. For patients with a cholecystostomy tube the tract can be dilated after it has matured in 6–8 weeks and a cholecystoscope can be inserted. The cholangioscope can be inserted through a 12F sheath and from here with direct visualization the stones can be fragmented via lithotripsy and percutaneously removed through the sheath.5–6 In a meta-analysis done by Kim et al. 2019, there was a technical success rate of 93–100% of percutaneous cholecystolithotomy using cholecystoscopy in high-risk patients with symptomatic gallstones. The complication rate ranged between 4% and 15% and was mostly related to bile leak during procedure or after catheter removal. The recurrence rate of gallstones was around 40%; however, patients who had recurrent symptoms were much lower at 12%.6

Interventions on choledocholithiasis traditionally have been performed through transhepatic biliary access, balloon dilation of the sphincter of Oddi and then pushing stones into the duodenum with a balloon catheter.5 In a retrospective study done by Garcia et al. 2004, for 212 patients with choledocholithiasis there was a 90.4% success rate of stone expulsion from the CBD using sphincteroplasty and balloon expulsion into duodenum. Of the 13 failures, the majority were attributed to the large size of the biliary stone.6 Newer devices using a cholangioscope and lithotripsy as previously discussed can also be used through transhepatic biliary access to break up and clear choledocholithiasis. In a retrospective study done by Gerges et al. 2021, 28 patients underwent percutaneous transhepatic cholangioscopy to determine safety and efficacy of common bile duct interventions. Technical success was defined as the ability to perform cholangioscopy with visualization of the lesion or stone and either successful biopsy of a lesion or complete lithotripsy and removal of stones. Successful intervention was achieved in 27/28 (96%) of cases with adverse events occurring in 3/28 (11%), all of which were transient bacteriemia.7 

In summary, there are numerous techniques and approaches available to interventionalists to percutaneously intervene on cholelithiasis and choledocholithiasis. These can be very beneficial to patients who are poor surgical candidates or have failed ERCP, with data supporting the efficacy and safety of such interventions. Additionally, preliminary studies on the use of cholangioscopy and cholecystoscopy with lithotripsy have been promising regarding both success rate and safety.  

References:  

Gallaher JR, Charles A. Acute cholecystitis: A review. JAMA. 2022;327(10):965–975. doi:10.1001/jama.2022.2350.

Chen H, Jorissen R, Walcott J, Nikfarjam M. Incidence and predictors of common bile duct stones in patients with acute cholecystitis: A systematic literature review and meta-analysis. ANZ J Surg. 2020 Sep;90(9):1598–1603. doi: 10.1111/ans.15565. Epub 2019 Nov 19. PMID: 31743951.

  1. Mallick R, Rank K, Ronstrom C, Amateau SK, Arain M, Attam R, Freeman ML, Harmon JV. Single-session laparoscopic cholecystectomy and ERCP: A valid option for the management of choledocholithiasis. Gastrointest Endosc. 2016 Oct;84(4):639–45. doi: 10.1016/j.gie.2016.02.050. Epub 2016 Mar 11. PMID: 26975235.
  2. ASGE Standards of Practice Committee, Buxbaum JL, Abbas Fehmi SM, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019; 89:1075.
  3. Ozcan N, Riaz A, Kahriman G. Percutaneous management of biliary stones. Semin Intervent Radiol. 2021 Aug;38(3):348–355. doi: 10.1055/s-0041-1731373. Epub 2021 Aug 10. PMID: 34393345; PMCID: PMC8354719.
  4. Kim SK, Mani NB, Darcy MD, Picus DD. Percutaneous cholecystolithotomy using cholecystoscopy. Tech Vasc Interv Radiol. 2019 Sep;22(3):139–148. doi: 10.1053/j.tvir.2019.04.006. Epub 2019 May 2. PMID: 31623754.
  5. García-García L, Lanciego C. Percutaneous treatment of biliary stones: Sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. AJR Am J Roentgenol. 2004 Mar;182(3):663–70. doi: 10.2214/ajr.182.3.1820663. PMID: 14975967.