title: Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones.
abstract: OBJECTIVE
  To report our approach for treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL).
  
  
  METHODS
  Twenty-two symptomatic patients (11 men and 11 women, age range 51 to 88 years) with intrahepatic or common bile duct calculi underwent PTBL. Nine patients had undergone previous gastrectomy and small-bowel anastomosis, thus precluding endoscopic retrograde cholangiopancreatography. In the other 13 patients, stone removal attempts by ERCP failed due to failed access or very large calculi. We used a 7.5F flexible ureteroscope and a 200-μm holmium laser fiber by way of a percutaneous transhepatic tract, with graded fluoroscopy, to fragment the calculi with direct vision. Balloon dilatation was added when a stricture was seen. The procedure was performed with the patient under general anaesthesia. A biliary drainage tube was left at the end of the procedure.
  
  
  RESULTS
  All stones were completely fragmented and flushed into the small bowel under direct vision except for one patient in whom the procedure was aborted. In 18 patients, 1 session sufficed, and in 3 patients, 2 sessions were needed. In 7 patients, balloon dilatation was performed for benign stricture after Whipple operation (n = 3), for choledochalenteric anastomosis (n = 3), and for recurrent cholangitis (n = 1). Adjunctive "balloon push" (n = 4) and "rendezvous" (n = 1) procedures were needed to completely clean the biliary tree. None of these patients needed surgery.
  
  
  CONCLUSIONS
  Complicated or large biliary calculi can be treated successfully using PTBL. We suggest that this approach should become the first choice of treatment before laparoscopic or open surgery is considered.
authors.affiliation: Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel-Hashomer, Affiliated to the Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel. rimonu@sheba.health.gov.il
authors.forename: Uri
authors.initials: U
authors.lastname: Rimon
authors.forename: Nir
authors.initials: N
authors.lastname: Kleinmann
authors.forename: Paul
authors.initials: P
authors.lastname: Bensaid
authors.forename: Gil
authors.initials: G
authors.lastname: Golan
authors.forename: Alexander
authors.initials: A
authors.lastname: Garniek
authors.forename: Boris
authors.initials: B
authors.lastname: Khaitovich
authors.forename: Harry
authors.initials: H
authors.lastname: Winkler
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002769:Cholelithiasis / Q000628:therapy*; D004724:Endoscopy / Q000379:methods*; D005260:Female; D005336:Fiber Optic Technology; D005471:Fluoroscopy; D006695:Holmium; D006801:Humans; D017602:Lithotripsy, Laser / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015641:Radiography, Interventional; D016896:Treatment Outcome
chemical_list: D006695:Holmium