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KUWAIT MEDICAL JOURNAL March 2006
ABSTRACT
The advent of extracorporeal shockwave lithotripsy
(ESWL) has extended the treatment armamentarium
for calculi outside of the urinary tract. The use of
ESWL for treatment of hepatic duct and pancreatic
calculi is well documented, particularly for those
that cannot be accessed by endoscopic retrograde
cholangio - pancreatography (ERCP). However,
not all stones can be treated by ESWL or accessed
by ERCP. We report the case of recalcitrant hepatic
duct calculi removed by the use of a semi rigid
ureteroscope after failure of all other methods of
treatment.
KEYWORDS: cholelithiasis, endoscopy, lithotripsy
Address correspondence to:
Dr. Ganesh Gopalakrishnan, Professor and Head, Dept of Urology, Christian Medical College and Hospital, Vellore-632 004, Tamilnadu, INDIA.
E-mail: ganeshgopalakrishnan@yahoo.com
Case Report
A Novel Use of Semi Rigid Ureteroscope for a Non Urological -
A Point of Technique
Shanmugasundaram Rajaian, Amitava Mukherjee, Ganesh Gopalakrishnan
Department of Urology, Christian Medical College, Vellore, Tamilnadu, India
Kuwait Medical Journal 2006, 38 (1): 56-58
INTRODUCTION
Expertise in the endourological techniques and
in handling endourological instruments has made
urologists to look beyond the urinary tract and help
in managing conditions where other tre a t m e n t
modalities have failed. Intra hepatic calculi cause
o b s t ruction, cholestasis, cholangitis, abscesses,
post-obstructive atrophy, biliary cirrhosis and
c h o l a n g i o c a rcinoma. They cause increased morbidity
and mortality due to these complications. The goal
in the management of intrahepatic calculi is to get
complete clearance of these calculi and to re s t o re
normal drainage of bile. The high rate of morbidity
and mortality associated with open surg i c a l
management has triggered the search for alternate
methods of treatment. The other tre a t m e n t
modalities like ERCP and ESWL have been used in
the management of these calculi. However, these
modalities have their own limitations due to
associated stone impaction, angulated ductal
anatomy, and large stone burden. We describe our
experience in managing such a situation successfully,
w h e re other modalities of treatment had failed to
retrieve the intrahepatic calculi.
CASE REPORT
A 43-year-old woman had a Type IV choledochal
cyst with choledocholithiasis (Fig. 1). She underwent
c yst excision and choledocholithotomy with hepatico-
jejunostomy five years ago. She p re sented recently to
surgery with abdominal pain, jaundice and fever.
During the work up she was found to have
multiple left hepatic duct calculi and cholangitis.
Percutaneous drainage of the obstructed biliary
tract (Fig. 2) was done and her cholangitis settled.
The percutaneous tract was allowed to mature for
two weeks. ESWL with Dornier compact S
lithotriptor was attempted for the clearance of
calculi, as there was difficulty in getting access to
the calculi by the endoscopic and percutaneous
methods. Since ESWL and other methods had
failed to remove the calculi, the urologist’s help
was sought for the retrieval of the calculi. Due to
the non-availability of laser, 8/9.8 Fr. Wolf semi
rigid ure t e roscope was used. The stones were
accessed and were fragmented using Swiss
lithoclast. The fragments were pushed into the
jejunum to be passed out via naturalis.
P e rcutaneous drainage of the biliary tract was
continued postoperatively. Postoperative cholangiogram
(Fig. 3) showed complete clearance of the calculi
and the drainage of bile was normal.
Technique
The attempt to remove the calculi by the
percutaneous route using a semi rigid ureteroscope
was made because of the maneuverability of the
tract passing through the left lobe of liver, being
unsupported by the costal margin. Multiple calculi
of about 1-1.5 cm size were noted on the
cholangiogram (Fig. 4). A 0.035-inch guidewire was
placed through the mature percutaneous tract. A10
Fr cobra catheter was then placed over the guide
57March 2006
A Novel Use of Semi Rigid Ureteroscope for a Non Urological - A Point of Technique
wire to accommodate another safety guide wire.
The tract was dilated up to 14 Fr using Teflon serial
dilators. A 8/9.8 Fr Wolf semi rigid ureteroscope
was introduced and stones were fragmented with
1.0 mm pneumatic intracorporeal probe. The
fragments were pushed into the jejunum and
washed out with the irrigating fluid. A12 Fr pigtail
catheter was placed over the guide wire in the
jejunum. Postoperative PTC showed complete
clearance of calculi (Fig. 3). The pigtail catheter was
removed after two weeks.
DISCUSSION
Hepatolithiasis is a potential cause of morbidity
and mortality. Biliary obstruction caused by
hepatic duct stones can lead to stricture ,
cholangitis, abscess formation, post-obstru c t i v e
atrophy, biliary cirrhosis and portal hypertension[1].
Before effective surgical and endoscopic methods
were introduced, treatment was often postponed or
neglected until the entire liver was involved or
biliary cirrhosis or cholangitis occurred [2]. Earlier,
treatment of these stones was by open surgical
methods. These procedures were associated with
high morbidity and mortality. Even with treatment,
it has been estimated that nearly 30% develop
recurrent stones, 18.7% need re-operation and 6.8%
have secondary biliary cirrhosis[3]. The attempts
made earlier to decrease the morbidity and
mortality of the open surgical procedures were
intraoperative stone localization using ultrasound
that avoids the critical blood vessels and normal
biliary ducts. The other method was to use ESWL
for fragmentation of the hepatic ducts stones[3].
Unfortunately, the former is an additional open
surgical procedure and the latter does not allow
drainage and clearance of fragments, if the stone
bulk is large or it is associated with strictures. The
lack of smooth muscle and peristalsis in the hepatic
and common bile duct is a further impediment to
stone clearance. For these reasons, percutaneous
approach for treating biliary stones was considered.
Percutaneous approach to intrahepatic stones
along with laser lithotripsy is considered a safe and
effective option for the recalcitrant stones in the
biliary tree[4]. There are potential complications of
the procedure but they are minor when compared
to the open procedure. When advanced techniques
Fig. 1: Endoscopic Retrograde Cholangio Pancreatography (ERCP)
showing the choledochal cyst with calculi and hepatic duct calculi Fig. 2: Preoperative cholangiogram via the drainage catheter placed in
the left hepatic duct showing the calculi
March 200658
like laser and small flexible endoscopes are not
available, semi-rigid ure t e roscope along with
pneumatic lithotripsy can be used as a method for
removing the recalcitrant hepatic duct calculi. The
c u r rent generation of semi-rigid ure t e ro s c o p e
incorporates fiberoptic light and image bundles
into smaller semi rigid metal sheath allowing much
v e r s a t i l i t y[ 5 ]. These fiberoptic imaging bundles
permit vertical flexibility of the endoscope without
causing image distortion (i.e. no half moon effect)[6].
The good extent of flexibility of the semi-rigid
metal sheath and tapered tip helps in negotiating
the acute angles during the manipulation without
causing image distortion and damage to the hepatic
ducts. Thus the urologists have a role in providing
expertise in small caliber endoscopy and lithotripsy
in other disciplines[7]. There is extensive data in the
l i t e r a t u re showing that the use of flexible
cholangioscope / ureteroscope and laser lithotripsy
is effective in the management of intrahepatic duct
calculi[4,7]. However, no report exists for treatment of
recalcitrant hepatic duct calculi using semi-rigid
ureteroscope and pneumatic lithotripsy. We have
described our own technique that has been used in
this patient successfully as a minimally invasive,
safe alternative to open surgery especially when
other modalities had failed to retrieve the calculi.
REFERENCES
1. Fan ST, Lai EC, Wong J. Hepatic resection for
hepatolithiasis. Arch Surg 1993; 128:1070-1074.
2. Jan Y Y, Chen MF, Wang CS. Surgical treatment of
hepatolithiasis, long-term results. Surgery 1996; 120:509-
514.
3. Wolf JS Jr, Stoller ML. Applications of Urological techniques
to nonurinary calculi. Urology 1990; 36:383-389.
4. Nadler RB, Rubeinstein JN. Percutaneous Hepatolithotomy,
The northwestern experience. J Endourology 2002; 16:293-
297.
5. Ferraro.RF, Abraham VE. A new generation of semi rigid
fiberoptic ureteroscopes. J Endourology 1999; 13:35-40.
6. Basillote JB, Lee DI, Eichel L. Ureteroscopes: flexible, rigid,
semirigid. Urol Clin N Am 2004; 31:21-31.
7. Tarman GJ, Lenert TJ. Holmium:YAG Laser lithotripsy of
intrahepatic biliary calculi. J Endourology 1999; 13:381-383.
Fig. 4: Preoperative cholangiogram showing the calculi and the guide
wire in position
Fig. 3: Postoperative cholangiogram showing complete clearance of the
calculi and the pigtail catheter across the hepaticojejunostomy
