Abstract: Objective:To investigate the application value of percutaneous sinustract cholangioscopy in the diagnosis and treatment of residual intra and extrahepatic bile duct stones.
Methods:The retrospective crosssectional study was conducted. The clinical data of 1 045 patients with intra and extra hepatic bile duct stones who underwent percutaneous sinustract cholangioscopy or stone extraction in the Second Affiliated Hospital of Zhejiang University from January 2003 to June 2016 were collected. Patients received percutaneous sinustract cholangioscopy or stone extraction at 6-8 weeks after T tube drainage. Observation indicators: (1) diagnosis and stone extraction situstions: cases with residual stones, stone extraction frequency and clearance rate; the critics of clearance rate are no residual stone during operation combined with B ultrasound or Ttube cholangiography; (2) postoperative complications: incidence and management of postoperative complications, prognosis and ClavienDindo classification for postoperative complication; (3) followup situation. Ttube was removed when there was no residual stone. Patients were followed up by outpatient examination up to April 2017. B ultrasound reexamination was performed to detect the recurrence of stone once every 3-6 months.
Results: (1) Diagnosis and stone extraction situstions: among 1 045 patients, results of cholangioscopy showed 147 wihout bile duct stones and 898 with bile duct stones.Of 898 patients, 2 618 times cholangioscopic explorations for stone extraction were performed, with a maximum frequency of 16 times, and 851 had stones clearance, with a overall clearance rate of 94.77%(851/898). The clearance rates of extra and intra hepatic bile duct stones were 100.00%(221/221) and 93.06%(630/677). Of 47 patients with residual stones, 16 didn′t receive cholangioscopy due to branches stricture or occlusion of intrahepatic duct, 13 failed to take out stone due to Ttube dislodgement (9 cases) and improper placement (4 cases) induced closed Ttube sinus tract, 7 had Ttube sinus tract duodenal fistula, 6 gave up stone extraction, 3 was due to longer sinus tract induced bending and 2 was due to Ttube sinus tract fracture. (2) Postoperative complications: among 1 045 patients, 297 had level Ⅰ-Ⅱ mild complications and 13 had level Ⅲ and above severe complications. The common complications included fever, vomiting, diarrhea and so on; the special complications included Ttube sinus tract duodenal fistula of 13 patients, Ttube sinus tract fracture of 4 patients, rupture of broken stones pole of 3 patients, massive hemobilia of 2 patients, acute pancreatitis of 2 patients and cardiac arrest of 1 patient. The above complications were improved by symptomatic and supportive treatments. (3) Followup situation: among 1 045 patients, 558 received longterm followup, with followup time of 10-171 months and a median time of 79 months. Eightfour patients had stone recurrence. Of 13 patients with recurrence of extrahepatic bile duct stones, 7 took out stones by endoscopic retrograde cholangio pancreatography (ERCP) and 6 underwent reoperations. Of 71 patients with recurrence of intrahepatic bile duct stones, 43 underwent reoperations and 28 received conservative treatment.
Conclusions:Percutaneous sinustract cholangioscopy for residual intra and extrahepatic bile duct stones is safe and effective, with good diagnosis and treatment values and a high clerance rate. The integrity of Ttube sinustract is a key of complete stones removal.