What post or posts were most valuable to you and why? VJ: The post by Karen T. Brown, MD, FSIR, recommending pushing the stones through was most attractive because it could potentially solve the patient’s problem without relying on another specialty and we already had the tools to accomplish this. The post by R. Torrance Andrews, MD, FSIR, regarding respecting the patient’s choice to have the drain removed was also useful because the patient was very adamant in this case, and we must balance medical indications with patient autonomy.


Will you, or have you, changed your practice patterns based off responses on SIR Connect? Please describe any changes you are considering. VJ: We were thinking of introducing a cholecystoscope system—however, we recently got interventional gastroenterology at our institution, so it makes cases like this easier to perform in conjunction with our gastroenterology colleagues.


Additional commentary Approximately 200,000 people a year in the United States are treated for acute cholecystitis (AC).1


It has also


been noted that approximately 13.7% of patients with acute cholecystitis have choledocholithiasis, which can lead to conditions such as cholangitis and pancreatitis.2


The well-known


standard of care for patients with AC is laparoscopic cholecystectomy. Patients with AC and clinically high probability of choledocholithiasis will often first undergo ERCP or, alternatively, stable patients can undergo cholecystectomy with intraoperative cholangiogram and intervention if required.3


Often IRs


become involved in the care of patients with AC and biliary obstruction when they are deemed too sick for surgery, ERCP has failed, is not available, or is not feasible due to postsurgical anatomy.4


In


these situations IR physicians are often tasked with placing a cholecystostomy tube for AC, or to decompress the biliary system with PTBD. In patients with choledocholithiasis or cholelithiasis who are never surgical candidates, it can be beneficial for IR physicians to have


the toolset and capability to perform percutaneous stone extraction.


Multiple techniques can be deployed in the setting of both cholelithiasis and choledocholithiasis that have been shown to be both safe and effective. For patients with a cholecystostomy tube the tract can be dilated after it has matured in 6–8 weeks and a cholecystoscope can be inserted. The cholangioscope can be inserted through a 12F sheath and from here with direct visualization the stones can be fragmented via lithotripsy and percutaneously removed through the sheath.5–6


In a meta-analysis


done by Kim et al. 2019, there was a technical success rate of 93–100% of percutaneous cholecystolithotomy using cholecystoscopy in high-risk patients with symptomatic gallstones. The complication rate ranged between 4% and 15% and was mostly related to bile leak during procedure or after catheter removal. The recurrence rate of gallstones was around 40%; however, patients who had recurrent symptoms were much lower at 12%.6


Interventions on choledocholithiasis traditionally have been performed through transhepatic biliary access, balloon dilation of the sphincter of Oddi and then pushing stones into the duodenum with a balloon catheter.5


In


a retrospective study done by Garcia et al. 2004, for 212 patients with choledocholithiasis there was a 90.4% success rate of stone expulsion from the CBD using sphincteroplasty and balloon expulsion into duodenum. Of the 13 failures, the majority were attributed to the large size of the biliary stone.6 Newer devices using a cholangioscope and lithotripsy as previously discussed can also be used through transhepatic biliary access to break up and clear choledocholithiasis. In a retrospective study done by Gerges et al. 2021, 28 patients underwent percutaneous transhepatic cholangioscopy to determine safety and efficacy of common bile duct interventions. Technical success was defined as the ability to perform cholangioscopy with visualization of the lesion or stone and either successful biopsy of a lesion or complete lithotripsy and removal of stones. Successful intervention was


achieved in 27/28 (96%) of cases with adverse events occurring in 3/28 (11%), all of which were transient bacteriemia.7


In summary, there are numerous techniques and approaches available to interventionalists to percutaneously intervene on cholelithiasis and choledocholithiasis. These can be very beneficial to patients who are poor surgical candidates or have failed ERCP, with data supporting the efficacy and safety of such interventions. Additionally, preliminary studies on the use of cholangioscopy and cholecystoscopy with lithotripsy have been promising regarding both success rate and safety.


References


1. Gallaher JR, Charles A. Acute cholecystitis: A review. JAMA. 2022;327(10):965–975. doi:10.1001/jama.2022.2350.


2. Chen H, Jorissen R, Walcott J, Nikfarjam M. Incidence and predictors of common bile duct stones in patients with acute cholecystitis: A systematic literature review and meta-analysis. ANZ J Surg. 2020 Sep;90(9):1598–1603. doi: 10.1111/ans.15565. Epub 2019 Nov 19. PMID: 31743951.


3. Mallick R, Rank K, Ronstrom C, Amateau SK, Arain M, Attam R, Freeman ML, Harmon JV. Single-session laparoscopic cholecystectomy and ERCP: A valid option for the management of choledocholithiasis. Gastrointest Endosc. 2016 Oct;84(4):639–45. doi: 10.1016/j.gie.2016.02.050. Epub 2016 Mar 11. PMID: 26975235.


4. ASGE Standards of Practice Committee, Buxbaum JL, Abbas Fehmi SM, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019; 89:1075.


5. Ozcan N, Riaz A, Kahriman G. Percutaneous management of biliary stones. Semin Intervent Radiol. 2021 Aug;38(3):348–355. doi: 10.1055/s-0041-1731373. Epub 2021 Aug 10. PMID: 34393345; PMCID: PMC8354719.


6. Kim SK, Mani NB, Darcy MD, Picus DD. Percutaneous cholecystolithotomy using cholecystoscopy. Tech Vasc Interv Radiol. 2019 Sep;22(3):139–148. doi: 10.1053/j. tvir.2019.04.006. Epub 2019 May 2. PMID: 31623754.


7. García-García L, Lanciego C. Percutaneous treatment of biliary stones: Sphincteroplasty and occlusion balloon for the clearance of bile duct calculi. AJR Am J Roentgenol. 2004 Mar;182(3):663–70. doi: 10.2214/ajr.182.3.1820663. PMID: 14975967.


irq.sirweb.org | 35


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40