The Management of Treatment-resistant Biliary Calculi Using Percutaneous Endourologic Techniques

Background: Complicated choledocholithiasis cannot always be managed by standard surgical, radiologic or endoscopic methods. One additional approach is to use percutaneous techniques developed by endourologists to treat renal calculi. In this report, we present our experience over the past 10 years with this novel approach.

Methods: We conducted a retrospective review of all patients who underwent percutaneous, endoscopic treatment of biliary calculi at our institution between January 1997 and August 2007. Primary outcomes of interest were symptom- and stone-free rates, length of stay in hospital and complications.

Results: Nineteen patients underwent 21 percutaneous treatments for biliary calculi. All were dependent on external drainage for symptom control. The primary indications for treatment were cholangitis, retained stone, biliary colic and jaundice. Seventeen patients (89.5%) had failed prior endoscopic retrograde cholangiopancreatography (ERCP) or open attempts at treatment. The 2 remaining patients (10.5%) were deemed unfit for a general anesthetic. Patients had experienced a mean of 1.8 (standard deviation [SD] 1.0) prior failed attempts at stone removal. We used several treatment modalities, including holmium:yttrium-aluminum-garnet laser (61.9%), electrohydraulic lithotripter (19.0%), ultrasound (9.5%), basket extraction (9.5%) and balloon dilatation of the ampulla (19.0%). Overall, treatment led to successful removal of the biliary drainage tube in 94.7% of patients and 76.2% were stone-free. We performed cholangiograms an average of 21.8 (SD 13.7) days after treatment. The average length of stay in hospital was 1.9 (SD 1.1) days. One patient experienced a perioperative acute coronary syndrome and another experienced prolonged biliary drainage. Both had successful endoscopic treatment of their calculi. There were no cases of treatment-related sepsis, and we observed no other complications.

Conclusion: Biliary calculi may be successfully treated using standard endourologic methods with high stone-free rates. This technique is generally well-tolerated even among high-risk patients.