Preliminary Clinical Efficacy Of Percutaneous Transcystic Papilla Balloon Dilation For Removing Common Bile Duct Stones

ObjectiveTo evaluate the feasibility,safety,and preliminary efficacy of percutaneous transcystic papilla balloon dilation for removing common bile duct stones.Methods29 patients with the common bile duct stones who were treated with percutaneous transcystic papilla balloon dilation in multiple center from March 2010 to November 2015 were analyzed retrospectively.Inclusion criteria:(1)patients were clearly diagnosed as common bile duct stones by ultrasound,CT or MRCP.(2)patients with poor general condition to tolerate endoscopic treatment or surgical operation or refuse ERCP or surgery.(3)patients with failed endoscopic treatment;(4)patients with no obvious dilatation of intrahepatic bile ducts.Exclusion criteria:(1)severe coagulation disorder which cannot be corrected;(2)platelet is less than or equal to 50*109/L;(3)patients with serious disease in heart,lung and brain and other organs;(4)renal or hepatic failure.The 29 cases were divided into two groups based on acute cholecystitis:a group of patients with common bile duct stones and no acute cholecystitis.Another group of patients with common bile duct stones combined with acute cholecystitis.In the group of common bile duct stones and no acute cholecystitis,there are 11 patients including 3 males and 8 females.And the average age is 67.7(52-91)years old.All patients had no obviously dilated intrahepatic bile ducts.6 patients were not suitable for endoscopic treatment or surgery,4 patients refused endoscopic or surgical treatment and 1 patient had a history of failed endoscopic treatment.The stone size were more than 1cm in 7 patients and less than 1cm in 4.In the group of common bile duct stones combined with acute cholecystitis,there are 18 patients including 8 males and 10 females.And the average age is 76(52-98)years old.In these 18 patients,5 patients had cardiac disease,4 patients had lung dysfunction,3 patients had uncontrolled diabetes mellitus,3 patients had poor general condition,2 patients had bleeding diathesis and lpatient had cerebrovascular disease.The stone size were less than 1cm in 9 patients,between 1 and 2cm in 6?and more than 2cm in 3.The white blood count,CA19-9,total bilirubin,direct bilirubin,AST,ALT and serum amylase level were recorded before the procedure,1 week,and 1month later for total 29 patients.Early complications,such as cholangitis,pancreatitis,hemorrhage,and perforation were evaluated.Follow up 2 years to observe the recurrence of stone and the incidence of reflux cholangitis.ResultsTechnical success was achieved in all 11 patients with common bile duct stones.The preoperative white blood cells were(8.21 ± 2.1)*109/L,and 1 and 1 months after the operation were reduced to(7.43 ± 1.9)*109/L and(7.16 ± 1.6)*109/L respectively.The preoperative CA19-9 was(149.50 ± 34.7)kU/L,and 1 and 1 months after operation were reduced to(117.6 ± 27.2)kU/L and(43.4 ± 11.9)kU/L.The total bilirubin was(138.4 ± 25.6)mmol/L before operation,and decreased to(69.8 ± 18.4)mmol/L and(14.3 ±2 3.3)mmol/L after 1 weeks and one month after the operation.Direct bilirubin was(99.8 ± 32.1)mmol/L before operation and decreased to(49.1 ±11.5)mmol/L and(8.6 ± 3.1)mmol/L after 1 and 1 months.The preoperative AST was(138.5 ± 26.1)mmol/L,and 1 and 1 months after operation were reduced to(49.3± 11.6)mmol/L and(23.4 ± 5.7)mmol/L respectively.The preoperative ALT was(175.4 ± 31.2)mmol/L,and 1 and 1 months after operation were reduced to(71.6 ±12.7)mmol/L and(31.8 ± 10.6)mmol/L respectively.The serum amylase was(154.1± 24.2)mmol/L before operation,and decreased to(145.7 ± 23.5)mmol/L and(149.6± 21.4)mmol/L after 1 and 1 months after operation.One patient suffered from biliary tract infection.No severe complications,such as perforation of biliary or gastrointestinal tract,occurred during the follow up.Common bile duct stone recurred in 1 patient 2 years after the procedure and the stone was pushed into duodunum by performing percutaneous transhepatic papilla balloon dilation duo to the poor general condition and the dilation of intrahepatic duct.For the 18 patients with common bile duct stones and acute cholecystitis,16 patients successfully pushed the stone to the duodenum.The procedure failed in 2 patients due to the large size of the stones.The largest stones were 24 and 25mm.The preoperative white blood cells were(15.73 ± 2.1)*109/L,and 1 and 1 months after the operation were reduced to(8.43 ± 1.9)*109/L and(7.26± 1.6)*109/L respectively.The preoperative CA19-9 was(145.50 ± 24.7)kU/L,and 1 and 1 months after operation were reduced to(116.6±17.9)kU/L and 46.4 ± 14.4)kU/L.The total bilirubin was(142.4 ± 19.6)mmol/L before operation,and decreased to(73.1± 16.1)mmol/L and(19.3 ± 1.2)mmol/L after 1 weeks and one month after the operation.Direct bilirubin was(102.4 ± 22.4)mmol/L before operation and decreased to(52.1 ±13.4)mmol/L and(9.7 ± 2.7)mmol/L after 1 and 1 months.The preoperative AST was(140.5±25.4)mmol/L,and 1 and 1 months after operation were reduced to(52.5±13.2)mmol/L and(29.5±16.1)mmol/L respectively.The preoperative ALT was(185.7±29.1)mmol/L,and 1 and 1 months after operation were reduced to(82.7±14.4)mmol/L and(32.1±12.1)mmol/L respectively.The serum amylase was(155.1±21.3)mmol/L before operation,and decreased to(147.7±21.7)mmol/L and(148.1±19.5)mmol/L after 1 and 1 months after operation.One patients developed bile peritonitis requiring percutaneous drainage in the early stage of the current study.The main reason for this complication was the premature removal of the gallbladder catheter.No symptomatic recurrence of cholecystitis or cholangitis occurred.ConclusionsFor cases who are not suitable for endoscopic treatment,surgery,or percutaneous transhepatic approach to treat the common bile duct stones and combined with acute cholecystitis,percutaneous transcystic papilla dilation is technically feasible and safe,and seems to be an appropriate alternative strategy.