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1 All authors: Department of Radiology, Hospital General Universitario de Alicante, C./ Pintor Baeza s.n., Alicante 03010, Spain.
Received April 14, 1999;
accepted after revision October 13, 1999.
Address correspondence to S. Gil.
Abstract
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SUBJECTS AND METHODS. During a 2-year period, 38 patients were treated percutaneously for stones in the biliary tree. Twenty-one patients were treated through a T tube or transcystic tract. Seventeen patients were treated through a transhepatic tract. Twenty-three patients had one stone each. Eight patients had two stones, and seven patients had three or more calculi. Stone size ranged from 3 to 16 mm in diameter (mean size, 6.7 mm). Balloon diameter based on the transverse diameter of the stones ranged from 7 to 18 mm (mean, 6.7 mm). An 11.5-mm occlusion balloon was used for pushing the stones through a 7- to 9-French vascular introducer. A catheter was left in the common bile duct from 1 to 6 days for external drainage.
RESULTS. The technique was successfully used for clearance of stones in 36 (94.7%) of the 38 patients. With 29 patients, the procedure was performed with only one attempt. Two attempts were necessary for five patients, and three attempts were necessary for four patients. Two major complications were cholangitis and biliary pleural effusion. No deaths were related to the procedure.
CONCLUSION. Percutaneous bile duct stone clearance by dilation of the papilla and evacuation of the stones in an antegrade fashion with an occlusion balloon is a safe and effective technique. It can be an alternative to basketing stones in selected patients.
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Percutaneous treatment of bile duct stones was first initiated by Mondet [5] in 1962 and Mazzariello [6] in 1970; however, Burhenne [7] expanded this technique and added the use of baskets for stone removal through the T-tube tract. Endoscopic clearance of bile duct stones (sphincterotomy) was first described in 1974 by Kawai et al. [8]. Since then, many newer and complementary techniques of both endoscopic and percutaneous approahces have been described [9,10,11,12,13,14,15,16,17].
Studies of balloon dilation of the papilla, whether by an endoscopic or transhepatic route, have been previously published, but little attention has been paid to this procedure in both endoscopy and radiology literature. We present our experience with percutaneous bile duct stone clearance to push the stones into the small bowel after balloon dilation of papilla. This study was performed with 38 patients.
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The study involved 22 women and 16 men, 37-87 years old (mean age, 59 years). In 21 patients, bile duct stones were retained after recent cholecystectomy. In 14 of 21 patients, the procedure was performed through a T-tube tract placed during open surgery (Fig. 1A,1B,1C,1D,1E,1F) and in seven patients through transcystic catheters placed in the common bile duct at laparoscopic cholecystectomy. In the remaining 17 patients, the procedure was performed through a percutaneous right transhepatic catheter placed as an internal or external bile drainage (Fig. 2A,2B,2C,2D,2E). In seven of these 17 patients, percutaneous transhepatic catheterization was performed primarily as drainage for cholangitis, and the clearance of bile duct calculi was performed secondarily. In four patients, the procedure was performed after diagnostic percutaneous transhepatic cholangiography revealed stones in patients with jaundice, and cross-sectional imaging revealed extrahepatic biliary obstruction of previously unknown cause.
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Finally, six of the 17 patients who underwent the transhepatic approach had conditions preventing endoscopic treatment (two patients with previous gastric surgery, three with periampullary diverticula, and one with a hepaticojejunostomy). Six of the 17 patients with percutaneous transhepatic catheterization had an in situ gallbladder, and the remaining 11 patients presented with bile duct stones diagnosed at least 2 years after cholecystectomy. Twenty-three patients had a single calculus, eight patients had two calculi, and the remaining seven patients had three or more. Two of these seven patients had too many stones to count. The minimum diameter of the stones ranged from 3 to 16 mm (mean diameter, 6.7 mm). In four patients, intrahepatic and extrahepatic biliary calculi were found. No patient had intrahepatic calculi exclusively. A hepaticojejunostomy was performed 6 years earlier in a patient with Crohn's disease. This patient presented with a stricture in the biliodigestive junction and with multiple calculi in the biliary tree.
In the patients without a T tube or transcystic catheter, the procedure began with percutaneous transhepatic cholangiography or biliary drainage. The clearing maneuvers were performed 0-5 days (mean time, 2 days) after initial biliary drainage. In two patients, these maneuvers were performed on the day of the initial drainage. Preliminary cholangiography with diluted contrast material was performed to define the anatomy of the biliary tree and the number, size, and location of stones.
Midazolam, atropine, and various analgesics were administered as necessary to 21 patients. Seventeen patients received deep sedation by an anesthesiologist. Patients received prophylactic broad-spectrum antibiotics if they had a recent history of cholangitis.
The procedure started by exchanging the catheter over a 145-cm 0.0035-inch diameter superstiff nitinol guidewire (Flexfinder; FlexMedics, Minnetonka, MN) with the tip located in the duodenum. This step was followed by the insertion of a 7- to 9- French vascular introducer sheath (Radiofocus; Terumo, Tokyo, Japan) with its distal tip in the biliary tree. A second cholangiography was performed after inserting the guidewire and the vascular introducer sheath to check the location of the stones and papilla. A standard low-profile 4-cm angiographic balloon (P1-PTA; OptiMed, Ettingen, Germany; or AXM; William Cook Europe, Bjaeverskov, Denmark) or a valvuloplasty balloon (VBC, William Cook Europe) was inserted over the guidewire and positioned across the papilla. Next, the balloon was inflated with diluted contrast material until the waist disappeared. Inflation was maintained for 30-60 sec, two or three times in each patient. The diameter of the balloon was equal to or slightly wider than the minimum diameter of the largest calculus and ranged between 7 and 18 mm.
After dilation, the balloon was removed carefully to avoid pulling the stones proximally into the intrahepatic tree and exchanged for an 11.5-mm biliary occlusion balloon (Weigand occlusion balloon; William Cook Europe). This balloon was inflated with diluted contrast material proximal to the stones and advanced over the guidewire through the papilla and into the duodenum. The balloon then pushed the stones into the duodenum. By controlling the volume of the balloon with the syringe, it was possible to modulate its size in the duct. Minor adjustments in balloon volume helped to pass it through the ampulla with less difficulty. This maneuver was repeated as many times as necessary. If difficulties arose, several procedures were helpful such as the IV administration of glucagon or nitrates (to relax Oddi's sphincter), dilating the papilla with a wider balloon, or advancing the introducer together with the occlusion balloon. We used this latter maneuver in most of the more recent patients and found it extremely helpful without increasing the number of complications.
If the stone was located in the intrahepatic bile ducts, a safety guidewire was left in the duodenum. Using angled catheter manipulation to get peripheral to the stones, we then placed a second guidewire in the intrahepatic duct. The occlusion balloon was then inserted and inflated according to the duct diameter beyond the calculus. When withdrawn, the balloon pulled the stone into the common bile duct and subsequently into the duodenum.
After the calculi were pushed into the duodenum (often confirmed as filling defects in the contrast agent-filled duodenum), the balloon and the introducer were removed, and a 6- to 8-French pigtail catheter was placed in the common bile duct, proximal to the papilla in 31 patients and transpapillar in the remaining seven patients. Except for the patient with the hepaticojejunostomy, this catheter remained in place for 1-6 days (mean time, 3 days) to allow drainage and prevent complications from papillary edema or injury. Before removing this catheter, a cholangiogram was obtained. If the biliary tree was free of calculi and easy flow of contrast material into the duodenum was shown, the catheter was removed and the patient was discharged. If calculi remained, we repeated the procedure as necessary. In the patient with the hepaticojejunostomy, a 14-French catheter was left through the stricture for 5 weeks for stenting. Follow-up of patients consisted of clinical evaluation, laboratory evaluation including liver enzymes and bilirubin levels, and abdominal sonography.
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In some patients mild abdominal pain, lasting from a few hours to 48 hr after the procedure, was relieved by analgesics. No clinical evidence of pancreatitis was found, although in four patients a mild transient elevation of serum amylase levels occurred. Several patients experienced transient vomiting and diarrhea as a result of contrast material in the duodenum. One patient had a modest amount of bleeding with clot formation that was treated by saline irrigation. No blood transfusion was necessary.
Two patients experienced major complications: one case of cholangitis and one case of biliary pleural effusion. The patient with cholangitis was treated with IV antibiotics with resolution after 48 hr. The patient with the biliary pleural effusion required drainage with a chest tube for 4 days and recovered without sequelae.
Follow-up of the patients revealed no recurrent biliary obstruction for a period of 3-24 months (mean time, 9 months). No patient died during this period. In the two patients in whom biliary stones are still present, no clinical episode of biliary obstruction has occurred, and no other procedure has been performed.
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Multiple percutaneous techniques have been described. These include transhepatic or T-tube catheter approaches, or more recently, catheterization through a transcystic tube; a modified stone basket technique [9]; monooctanoin stone-size reduction [10]; methyl tert-butyl ether common duct calculi dissolution [11]; percutaneous intracorporeal electrohydraulic lithotripsy [12]; laser lithotripsy [13]; extracorporeal shock-wave lithotripsy [14]; and electromagnetic lithotripsy [15]. Most of these techniques can also be performed with an endoscopic approach. Combined techniques and approaches have also been used [16, 17] and other researchers have incorporated the use of a choledoscope [12, 13].
All the techniques cited previously have advantages and disadvantages, but most of them require complex and, in some cases, expensive equipment. Moreover, both endoscopic and percutaneous approaches have complications such as bleeding, perforation, pancreatitis, and sepsis. The optimal treatment method has not yet been established.
Balloon dilation of the papilla to allow stones to pass into the duodenum has been described for both the transhepatic and endoscopic routes as a safe and successful technique. However, comparing it with other techniques has received little attention in the radiology and endoscopy literature. In 1983, endoscopic papillary balloon dilation was proposed by Staritz et al. [18] as a less hazardous alternative to endoscopic sphincterotomy in a small series of 11 successfully treated patients. May et al. [19] in 1993 and Mac Mathuna et al. [20] in 1994 reevaluated this technique. Later, in 1995, Mathuna et al. [21] reported a larger series of 100 patients. In 1997, Bergman et al. [22] reported a randomized study of endoscopic papillary balloon dilation versus endoscopic sphincterotomy. Bergman et al. concluded that endoscopic papillary balloon dilation is a valuable alternative to endoscopic sphincterotomy. More recently, Komatsu et al. [23], in their experience with 226 patients, concluded that endoscopic papillary balloon dilation might become a standard procedure for the treatment of common bile duct stones in the future.
Even less attention has been paid to percutaneous papillary balloon dilation in the radiology literature. In 1981, Centola et al. [24] described a patient in whom they performed percutaneous papillary balloon dilation and flushed a small retained stone into the duodenum. In 1982, Fataar et al. [25] reported another case in which they dilated the papilla with a 5-mm balloon and pushed the stone with the same balloon. In 1986, Meranze et al. [26] described a series of 16 patients in whom they eliminated retained common bile duct stones by pushing them into the duodenum with an angiographic occlusion catheter. They dilated the papilla only when the calculi were large. In 1988, Berkman et al. [27] reported a series of 17 patients in whom they dilated the papilla and pushed the stones with a standard angiographic catheter. Since then, to our knowledge, only one series of five dilations and transpapillar stone clearance performed through a T-tube tract has been described in the literature [28].
Despite these reports, balloon dilation of the papilla has not gained wide acceptance. Reluctance to use this method may arise from a belief that sphincter dilation is risky. A pancreatitis rate of 25% is often mentioned; however, this rate is derived from a study of balloon dilation in suspected Oddi's sphincter dysfunction in which two of eight patients developed pancreatitis [29]. In our series, no clinical evidence of pancreatitis was seen, although some patients had mild abdominal pain that resolved in a few days. In four patients, mild transient asymptomatic elevation of serum amylase levels occurred.
Other concerns about this technique are the short- and long-term consequences of papilla dilation, especially in young patients. In 1996, Mac Mathuna et al. [30] in animal research on pigs showed that balloon sphincteroplasty caused an acute transmural inflammatory response and chronic follicular hyperplasia that was not associated with fibrosis or altered papillary architecture or function. Minami et al. [31] reported that sphincter function could be preserved after balloon dilation.
Failure to completely eliminate bile duct calculi is often related to long, narrow, and tortuous tracts. Therefore, it is important to communicate to the surgeons the importance of placing an adequate access tract to the biliary tree [32].
Choosing the proper equipment is a major determinant of the success of the procedure. For better transmission of force and to avoid kinking, a stiff guidewire is necessary. The routine use of vascular introducers also helps to transmit the force. Moreover, the introducer can be used to administer contrast material, prevent air bubbles, and avoid tract injury, thereby decreasing the patient's discomfort during the procedure. Finally, the occlusion balloon is one of the most important materials in this procedure. The one we use is specific for biliary procedures. It is short and stiff for better force transmission with the guidewire, and it resists kinking.
The major advantage of this technique in comparison with the stone basket technique is that only a 7- to 9-French tract is needed. This advantage is especially important with a transhepatic approach; hence, mature tracts are not necessary.
Another merit of this procedure is that it is simple and quick, and many stones can be pushed in a single attempt, decreasing the amount of radiation for both the patient and the radiologist.
In our series, 17 dilations were performed through the transhepatic route, six of them with an in situ gallbladder. This technique, in our opinion, is not only indicated with re-cent cholecystectomy (T-tube or transcystic routes) but also in any case of choledocholithiasis if a transhepatic catheter is placed in the biliary tree. However, we do not attempt this procedure when calculi are larger than 18-20 mm or in those patients with cholecystolithiasis who are candidates for cholecystectomy.
In conclusion, percutaneous bile duct stone clearance by dilation of the papilla and then pushing the stones in an antegrade fashion with an occlusion balloon is a safe and effective technique. It can be an alternative to basketing of stones in selected patients.
Acknowledgments
We thank Steve Kjobech for his corrections to the manuscript.
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