This ASG video tip is sponsored by Braintree, maker of the newly approved Suflav and Sutab. Percutaneous endoscopic biliary lithectomy, an alternative to ERCP and cholecystectomy. Our disclosures are listed below. Patients with biliary obstruction due to cholelithiasis or choledoglythiasis typically undergo endoscopic retrograde cholangiopancreatography, or ERCP, and subsequent cholecystectomy for treatment of their disease. Percutaneous cholecystostomy tubes are commonly performed in patients with biliary disease with significant comorbidities that pose prohibitive operative risk. PTC drains are usually palliative procedures and serve as a bridge to surgical therapy. However, these drains can be offered to those who refuse surgical intervention, as they can be kept in place indefinitely. PTC drains aren't benign, however, and are associated with pain, leakage of bile around the drain, bleeding, and dislodgement. Advances in endoscopic surgery has led to innovative methods to treat biliary disease. Percutaneous endoscopic biliary lithectomy is an alternative approach to treating cholelithiasis and choledocolithiasis in patients with prohibitive operative risk and can be performed easily in the outpatient setting. This single-operator system utilizes the existing PTC drain tract to allow direct visualization of the gallbladder and biliary system. A disposable 10-french flexible choledocoscope provides a therapeutic working channel that allows the use of baskets, snares, lithotripsy, and can also be used in conjunction with laser lithotripsy systems. This case series will focus on two unique patients who underwent percutaneous endoscopic biliary lithectomy for treatment of cholelithiasis or choledocolithiasis. The first patient is a 62-year-old female with a history of pancreatic divisum complicated by multiple bouts of pancreatitis, requiring multiple ERCPs and stent placements. Her most recent ERCP was complicated by duodenal perforation requiring Roux-en-Y reconstruction. She has also undergone multiple small bowel resections, leading to short gut syndrome for which she is TPN-dependent. She developed acute cholecystitis with evidence of common bile duct dilation to 12 millimeters with intra- and extra-hepatic ductal dilation without evidence of cholangitis. Her chronic medical conditions and extensive surgical history resulted in prohibitive operative risk necessitating placement of a PTC drain. She underwent ultrasound-guided PTC drain placement with a 10 French multipurpose drain. She was found to have purulent fluid within the gallbladder, and the cystic duct was completely occluded on cholecystogram. She underwent outpatient PTC drain replacement, which was upsized to a 16 French drain in preparation for her PEBL procedure. We began by performing a cholecystogram through the PTC drain, which demonstrated contrast within the gallbladder, a patent cystic duct, and contrast within the common bile duct into the duodenum. Using a Seldinger technique, we advanced our 10 French disposable choledocuscope into the gallbladder. Insufflation of the gallbladder was achieved with normal saline, and the distal gallbladder to the cystic duct was devoid of any stones. Multiple attempts to enter the cystic duct were made, however unsuccessful due to the duct's small size. Examination of the remainder of the gallbladder revealed stones within the fundus that were easily extracted with a tipless nitinol basket. Repeat examination of the entire gallbladder under insufflation and desufflation revealed no remaining stones. We concluded the procedure with a completion cholecystogram, which demonstrated a patent cystic duct without any filling defects within the common bile duct. Contrast flowed freely into the duodenum. We elected not to replace the PTC drain due to the successful stone extraction. The second case scenario involves a 61-year-old male with a history of complex foregut surgery as an infant. He presented with cholecystitis and choledocholithiasis with a 6mm common bile duct stone, and underwent attempted laparoscopic cholecystectomy, however was aborted due to severe adhesive disease. He instead underwent placement of a 14 French PTC drain. Following this, he had two attempted ERCPs, however the ampule was unable to be identified on both occasions. Due to his prohibitive operative risk, as well as his failed ERCPs, he was taken to the operating room for a PEBL procedure. His first procedure began with a cholecystogram through the PTC drain, which demonstrated a large filling defect in the gallbladder and multiple filling defects in the common bile duct. During this procedure, we were able to extract gallstones from the gallbladder and distal common bile duct using a tipless nitinol basket. At the conclusion of this procedure, there were multiple small fragments remaining within the gallbladder that were thought to be sufficiently small enough to pass spontaneously. A completion cholecystogram was performed which demonstrated no filling defects within the gallbladder or common bile duct. A 14 French pigtail drainage catheter was placed through the existing tract and he was discharged the same day. The patient was seen in follow-up clinic and requested removal of the PTC drain. Unfortunately, he presented to another hospital a few months later with recurrence of his symptoms requiring repeat placement of a 12 French PTC drain. He was taken back to the operating room 8 months after his initial PEBL procedure for repeat exploration. We began with a cholecystogram which demonstrated filling defects within the common bile duct, however contrast was seen filling the duodenum. We removed the drain over a guide wire and advanced the 14 French dilating sheath over the wire. We then advanced our disposable choledoscope into the gallbladder. Examination of the gallbladder revealed no evidence of stones. The endoscope was then advanced over a wire into the common bile duct where a large stone was appreciated along with stone debris. The small stone debris was successfully extracted with multiple passes using a tipless nitinol basket. We then utilized electrohydraulic lithotripsy to fracture the large stone into fragments that were small enough to be extracted through the cystic duct. We used a tipless nitinol basket to successfully remove all of the large fragments from the common bile duct. Further examination of the common bile duct revealed no additional stones. The endoscope was then advanced to the level of the ampulla and the wire was passed through the sphincter into the duodenum. A 14 French drain was passed across the ampulla and secured in place. A completion cholecystogram revealed contrast within the common bile duct without any evidence of obstruction. Three weeks later he returned for a repeat PEBL procedure which demonstrated some residual stone debris in the distal common bile duct that was easily cleared using a tipless nitinol basket. The completion cholecystogram demonstrated no evidence of obstruction or filling defects. At that time we elected not to replace his PTC drain and he was seen in clinic six weeks later without recurrence of his symptoms, tolerating a normal diet, and his previous drain site was well healed. In summary, both of these cases demonstrate successful treatment of cholelithiasis and choledocholithiasis in patients with a PTC drain due to prohibitive operative risk. The PEBL procedure is a safe and effective alternative to ERCP and cholecystectomy for the treatment of cholelithiasis or choledocholithiasis and can eliminate the need for a long-term PTC drain and its associated morbidity. If patients have recurrence of their symptoms, replacement of the PTC drain is an option with repeat PEBL procedure as necessary. Physicians should consider referral to a surgical endoscopist for PEBL procedure in patients with prohibitive operative risks who have a PTC drain in place for cholelithiasis or choledocholithiasis.

Percutaneous Endoscopic Biliary Lithectomy

PEBL

cholelithiasis

choledocholithiasis

ERCP alternative