| BackgroundBile duct stones are classified as intrahepatic(hepatolithiasis)and extrahepatic bile duct stones.Extrahepatic bile duct stones include common hepatic duct stones and common bile duct stones.Bile duct stones are divided into primary bile duct stones and secondary bile duct stones according to different sources.Primary bile duct stones are mainly pigment stones,which are more common in East Asia.The source of secondary bile duct stones is from gallbladder,often cholesterol gallstones,which are more common in Western societies.Hepatolithiasis accounts for about 20%-30%of cholelithiasis and about 70%of patients with intrahepatic stones suffered from extrahepatic bile duct stones.Frequently bile duct stones are asymptomatic.The symptoms of bile duct stones(mainly common bile duct stones)include abdominal pain,jaundice,and cholangitis.There are many methods for treatments of intrahepatic and extrahepatic bile duct stones,including surgery,endoscopic sphincterotomy(EST),percutaneous transhepatic cholangioscopy(PTCS),percutaneous transhepatic papilla balloon dilation(PTBD),extracorporeal shock-wave lithotripsy(ESWL),Neodymium-doped Yttrium Aluminum Garnet laser lithotripsy(NdYAG)and electrohydraulic shock-wave lithotripsy.During last decades laparoscopic surgery replaced conventional open abdominal surgery.This procedure has a low-cost,short hospitalization and early recovery.The recurrence rate of calculi,the incidence of secondary cirrhosis and cholangiocarcinoma after surgery is low,but postoperative complications are still significant.Endoscopic retrograde cholangiopancreatography(ERCP)is widely used in the treatment of extrahepatic stones,but it is more difficult to treat intrahepatic bile duct stones.The complications rate may be signi:ficant including hemorrhage,severe pancreatitis,duodenal perforation and even death.In addition,ERCP cannot be performed after previous surgery with disconnection of the bile duct with drainage through a Roux loop.Therefore,there is an urgent need to find small traumatic,simple,safe and reliable method for treating intrahepatic bile duct stones.At present,there are no reports on the application of PTBD in the treatment of intrahepatic bile duct stones.Based on years of PTBD stones removal,we proposed the idea of PTBD in the treatment of intrahepatic and extrahepatic bile duct stones.This study aims to evaluate the feasibility,safety and efficacy of this procedure.Objective1.To evaluate the safety and feasibility,of PTBD for removing intrahepatic and extrahepatic bile duct stones.2.To evaluate the clinical efficacy of PTBD.Clinical material and methodsTwenty-eight patients with intrahepatic and extrahepatic bile duct stones who were treated with PTBD in different medical centers from March 2014 to November 2016 were enrolled.All of them were treated with PTBD.Inclusion criteria:(1)intrahepatic stones in the right and/or left hepatic duct with symptoms of cholangitis,such as obstructive jaundice,pain or fever;(2)intrahepatic stones,with psychological anxiety;(3)inability to tolerate or refusal to undergo general anesthesia with tracheal intubation because of severe comorbidities such as cardiopulmonary disease;(4)inability to tolerate or refusal to undergo surgical,laparoscopic or cholangioscopic procedures;(5)predicted life span of≥1 year;(6)Karnofsky score>70.Exclusion criteria:(1)extrahepatic bile duct stone with a diameter>2.5cm;(2)more than three intrahepatic stones;(3)severe cardiac insufficiency(New York Heart Association class Ⅲ-Ⅳ)or advanced lung disease(determined by consultation with respiratory disease specialists),liver disease(Child-Pugh class C),or kidney disease(grade 3 chronic kidney disease);(4)severe coagulopathy(prothrombin time>17s and/or platelet count<60×≡012/L).All patients have had intrahepatic and extrahepatic bile duct stones.There were 13 males and 15 females,with an average age of 66.64±14.00 years(31-87 ages).Twenty-three patients could not tolerate open surgery,laparoscopic or endoscopic treatment due to severe hypertension,coronary heart disease,pulmonary insufficiency or cerebrovascular accident(CVA).Three patients rejected open surgery,laparoscopic or endoscopic treatment.The remaining 2 patients had recurrence of stones after surgery.Extrahepatic bile duct stones size was more than 1.5cm in 13 patients,between 1 and 1.5cm in 14,and less than 1cm in 1.The maximum size of extrahepatic bile duct stones was 2.5cm and the average size of stones was 1.65+0.58cm.The intrahepatic stones were between 1 and 1.5cm in 15 patients and less than 1cm in 13.The maximum size of intrahepatic stones was 1.5cm and the average size of stones was 0.99±0.26cm.The intrahepatic stones were located in left intrahepatic duct in 10 patients,right intrahepatic duct in 7 patients and in both ducts in 11 patients.White blood count,total bilirubin,direct bilirubin,ALT,AST,CA19-9 and serum amylase level were recorded before the procedure and 1 week after operation.Early complications,such as residual stones,hemorrhage,infection,pancreatitis or perforation were evaluated.Two patients underwent percutaneous transhepatic biliary drainage for severe suppurative cholangitis.PTBD was performed after clinical improvement of patients.In order to improve the success rate,5 patients underwent stone extractor lithotripsy,and 2 patients underwent laser lithotripsy during PTBD procedure.Two to four years follow-up to observe stones recurrence and the incidence of long-term complications was performed.All data were analyzed or compared using statistical methods.ResultsStones of 26 patients were successfully removed with a success rate of 92.86%.In 1 patient,the CBD stone was too big to be removed.The intrahepatic bile duct stone in another patient failed to be removed because of severe intrahepatic bile duct stenosis and big intrahepatic bile duct stone.Both patients were transferred to surgical ward after family members explanation.White blood count,TBIL,DBIL,ALT,AST and CA199 one week after PTBD were lower than before,with significant difference.Serum amylase level were also lower than before,but with no significant difference(table 2).Two patients underwent repeated balloon dilation to passage stones into the duodenal lumen because of residual stones 1 week after operation.One patient had symptoms of fever and abdominal pain after removal of the extra-biliary drainage tube 1 week after operation.He was considered to have localized peritonitis,examined by surgical consult and discharged after conservative treatment 7 days later.No complications such as bleeding,infection,pancreatitis or perforation occurred after operation.After 2 to 4 years follow up,there was no evidence of extrahepatic and intrahepatic bile duct stones recurrence.What’s more,there was no cases of chronic cholangitis,secondary biliary cirrhosis and intrahepatic cholangiocarcinoma.There were no significant complications or patient death.ConclusionsThe results of preliminary studies proved that PTBD is effective in the treatment of intrahepatic and extrahepatic bile duct stones with high success rate and less postoperative complications.It is especially suitable for patients with endoscopic failure or surgical contraindications,providing a safe,feasible and effective new treatment method. |
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