Percutaneous Treatment of Biliary Stones: Sphincteroplasty and Occlusion Balloon for the Clearance of Bile Duct Calculi

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Percutaneous Treatment of Biliary Stones: Sphincteroplasty and Occlusion Balloon for the Clearance of Bile Duct Calculi

Lorenzo García-García¹ and Carlos Lanciego

¹ Both authors: Unidad de Radiología Intervencionista, Hospital Virgen de la Salud, Complejo Hospitalario de Toledo, Avenida Barber s/n, Toledo 45004, Spain.

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Fig. 1A. —56-year-old man who had undergone cholecystectomy 3 months earlier and who, after undergoing cholangiography and surgery, had suspected retained calculus. Cholangiogram through T tube (Kher tube) shows obstructive calculus (arrow) in distal portion of common bile duct.

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Fig. 1B. —56-year-old man who had undergone cholecystectomy 3 months earlier and who, after undergoing cholangiography and surgery, had suspected retained calculus. Cholangiogram shows exit of guidewire through opening between two arms of T (arrow).

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Fig. 1C. —56-year-old man who had undergone cholecystectomy 3 months earlier and who, after undergoing cholangiography and surgery, had suspected retained calculus. After guidewire passed papilla (not shown), papilloplasty was performed with 10-mm balloon catheter. Arrow indicates site of calculus above inflated balloon.

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Fig. 1D. —56-year-old man who had undergone cholecystectomy 3 months earlier and who, after undergoing cholangiography and surgery, had suspected retained calculus. Cholangiogram shows occlusive balloon (Fogarty-type) inflated with air (arrow) above calculus and with introducer located in entrance of main biliary duct.

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Fig. 1E. —56-year-old man who had undergone cholecystectomy 3 months earlier and who, after undergoing cholangiography and surgery, had suspected retained calculus. Follow-up cholangiogram obtained at conclusion of intervention shows complete clearance of bile duct calculi.

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Fig. 2A. —66-year-old woman who had undergone percutaneous transhepatic drainage the previous week because of cholangitis. Cause was stone impacted or embedded in distal papilla resulting in obstruction of main bile duct. Cholangiogram shows spontaneous dislodgement of calculus (arrow) and guidewire passing papilla into duodenum.

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Fig. 2B. —66-year-old woman who had undergone percutaneous transhepatic drainage the previous week because of cholangitis. Cause was stone impacted or embedded in distal papilla resulting in obstruction of main bile duct. Next cholangiogram obtained after A shows papilloplasty performed with 12-mm balloon after retrograde movement of calculus (arrow) into intrahepatic biliary tree and precluding papilloplasty balloon from compressing calculus against biliary wall.

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Fig. 2C. —66-year-old woman who had undergone percutaneous transhepatic drainage the previous week because of cholangitis. Cause was stone impacted or embedded in distal papilla resulting in obstruction of main bile duct. Cholangiogram shows filling defect corresponding to calculus (arrow) in trough of duodenal diverticulum.

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Fig. 2D. —66-year-old woman who had undergone percutaneous transhepatic drainage the previous week because of cholangitis. Cause was stone impacted or embedded in distal papilla resulting in obstruction of main bile duct. Cholangiogram obtained 2 days after placement of external drainage catheter shows complete absence of calculus in bile duct.

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Fig. 3A. —56-year-old man with residual intrahepatic lithiasis after having undergone cholecystectomy 2 months previously. Size of calculus is considerable for this site and completely blocks bile duct. Cholangiogram obtained through T tube shows site of residual intrahepatic stone (arrow).

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Fig. 3B. —56-year-old man with residual intrahepatic lithiasis after having undergone cholecystectomy 2 months previously. Size of calculus is considerable for this site and completely blocks bile duct. Cholangiogram shows T tube exchanged for introducer after passage of guidewire beyond calculus (arrow). Occlusion balloon catheter is inflated so its diameter adapts to size of calculus (arrow). It is pulled gently, but firmly, from below to force calculus to descend into main bile duct.

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Fig. 3C. —56-year-old man with residual intrahepatic lithiasis after having undergone cholecystectomy 2 months previously. Size of calculus is considerable for this site and completely blocks bile duct. Cholangiogram shows that calculus appears fragmented (arrow) and descends toward common bile duct.

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Fig. 3D. —56-year-old man with residual intrahepatic lithiasis after having undergone cholecystectomy 2 months previously. Size of calculus is considerable for this site and completely blocks bile duct. Cholangiogram shows maintenance of intrahepatic guidewire as safety; second guidewire is passed across papilla into duodenum.

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Fig. 3E. —56-year-old man with residual intrahepatic lithiasis after having undergone cholecystectomy 2 months previously. Size of calculus is considerable for this site and completely blocks bile duct. Follow-up cholangiogram shows intra- and extrahepatic bile ducts completely clear of calculi.

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