Percutaneous Approach for Removal of Difficult Common Bile Duct Stones

duct stone disease is one of the most common problems in medical practice. Surgical common bile duct (CBD) exploration was the procedure of choice for the treatment of bile duct stones a few decades ago. However, endoscopic retrogr-ade cholangiopancreatography (ERCP) with sphincterotomy has become the treatment of choice for bile duct stones after the development of ERCP techniques. Development of devices and techniques used in endoscopic sphincterotomy and stone extraction has increased the success rate of stone removal. Meanwhile, endoscopic sphincterotomy may be difficult or impossible in some clinical situations, including duodenal or pyloric stenosis, unusual biliary anatomy, previous gastroin-testinal surgery such as Billroth II and Roux-en-Y gastrojeju-nostomy reconstruction, bilioenteric anastomosis, and pa-tients' intolerance. As a surgical modality, laparoscopic biliary surgery has been widely used. Laparoscopic CBD exploration (transcystic or transcholedochal) is the most commonly used method for managing difficult CBD stones. However, general anesthesia is necessary to perform the surgery and the cost of the procedure is high. The success rate in performing laparo-scopic CBD exploration is approximately 86% to 95% with 5% to 18% complication rates. 1 Percutaneous transhepatic stone removal is another important technique among the non-operative managements of bile duct stones. Percutaneous tr-anshepatic stone extraction and expulsion into the duodenum was first reported in 1979. 2 Percutaneous transhepatic cholan-gioscopy (PTCS) can be combined with these techniques. Balloon dilatation of the sphincter of Oddi has been widely used to facilitate stone removal procedure in order to allow biliary stone passage. Several techniques including basket forceps, electrohydraulic lithotripsy (EHL), and laser lithotripsy are now available for fragmentation of large stones. 3 Variable major and minor complications of this technique including chol-angitis, biliary pleural effusion, and self-limiting hemobilia have been reported. Lee et al. 4 reported 100% success rate of PTCS lithotomy for removal of difficult CBD stones in 33 cases. EHL was used in most patients. Complications related with PTCS lithotomy, including fever, pancreatitis, and hemobilia, occurred in 15 patients (45.5%) but were ameliorated with conservative management. The mean procedure number of PTCS lithotomy was 2.8 and the numbers of EHL session were one session in 16, two sessions in nine, three sessions in five, and more than four sessions in two patients. The major indications of PTCS were altered anatomy due to previous stomach surgery (16 cases) and impacted stones (11 cases). Fifteen patients had prior cholecystectomy, but the paper did not mention the presence of gallbladder …