대 한 방 사 선 의 학 회 지 1992 ; 28 (5) : 754~ 759 Journal of Korean Radiological Society, September, 1992

Percutaneous Removal of Residual Intrahepatic Stones through Transjejunal T-tube Tract

Byung Hee Lee, M.D. , Yong Lee, M.D.* , Young Soo Do, M.D. , Hong Sik Byun, M.D. , Kie Hwan Kim, M.D. , Soo Yil Chin, M.D. ,

Departmeηt 01 Diagηostic Radiology, Korea Caηcer Ceη ter Hospital

INTRODUCTION

Interventional procedures for residual biliary

stones are well established (1-3)

In cases of biliary-jejunal anastomoses , the

route of interventional access is usually T-tube

choledochostomy tract. But in cases of recurrent

pyogenic cholangiohepatitis , the extraction of

residual intrahepatic stones through conventional

T-tube choledochostomy tract is troblesom e due

to multifocal intrahepatic biliary strictures , multiplicity of stones , impacted stones , and the

large size of stones. Thus , repeated interven­

tional procedures with complex techniques such

as dilatation of strictures and crushing of stones

a re mandatory (4-6)

W e required the surgeon to place a T -tube at

jejunal site for removal of residual biliary stones

in ten patients with choledochojejunostomy. In

all cases , T-tube was inserted into jejunum , and

its upper limb was placed within the CBD

through the anastomotic site. Interventional in­

struments, then , were introduced into the je-

Index Words: Bile ducts , rad iography 76.1225

Bile ducts, stone extraction 76.1228

Bile ducts, anastomosis 76.453

*영동방사선과의원

* Youηg Doηg Radiology Cliηz‘c

junum and manipulated in the biliary tree

through the anastomotic site. With this ap­

proach , we could successfully retrieve residual

biliary stones in bulk through the anastomotic

site and release the stones in the jejunallumen

Large stones also could be re trieved easily into

the jejunal lumen without crushing

Our experience suggests that this approach

can provide simpler and time saving access for

removal of residual bilia ry stones in cases of

choledochojejunostomy , and can avoid additional

operations such as attaching j ejunal segment ex­

traperitoneally beneath the abdominal wall (7)

MATERIALS AND METHODS

Form M a rch , 1990 to D ecember , 1991 , per­

cutaneous transjejunal T-tube approach for

removal of residual intrahepatic stones was per­

formed in ten patients. The patients ' age rang­

ed from 22 to 54 years . There were eight female

and two male patients (Table 1)

Nine patients who had CBD diam eter of

2 .5cm or more , underw ent Roux- e n- Y

choledochoj ejunostomy . In one patient , who

already had undergone side-to-end choledocho­

jejunostomy at other hospital , we inserted T-tubc

이 논문은 1992년 6월5일 접수하여 1992년 8월 7일 채택되었음.

Received June 5, Accepted August 7, 1992

754 -

Byung Hee Lee , et al : Percutaneous Removal of Residual Intrahepatic Stones through Transjejunal T-tube Tract

Table 1. Details of R esults in 10 Patients

R esult Sessions Stricture R esidual stone Op. Patient No.

S ‘ R

2. 3. 4.

5.

6 7.

8 9.

10

Complete Complete Complete Complete Complete

Complete Complete Complete Complete Complete

?•

q4

1i

q• ’1

?{ qJ

。4

이4 ?ι

B.D

n/-

’i n/-

이/-

Minimal

Multiple

Mult iple Multiple

No % % 1 % 3

% % 3 % %

Location

Rt .IHD R t. IHD L t. IHD R t. IHD L t. IHD

L t. IHD Both IHD

R t. IHD Both IHD

R t. IHD

y‘ yi

X‘ yi

J Y Xi

y‘ y‘ y‘

R

R

R

R C

R

R

R

R

R

Age (yr) /Sex

49/F

31/F

221M

49/F

311F

54/F

54/F

46/M

5'5/F

45/F

2 Multiple Minimal

* R-Y: Roux-en-Y operation. C-J : Side-to-end choledochojej unostomy * B.D : Balloon dilatation. S.R: Stone removal

was positioned across the strictured segm ent over

a guide wire and usually was in f1 ated 3 times at

the maximum allowable pressure. Sometimes

larger balloons (diameter 12mm-25mm) were us­

ed in the cases with large stones , in expectation

of crushing the stones into small fragments as

w ell as dilating the strictured bile ducts. In the

cases with the lumen of the stricture segment

smaller than that of the prein f1ated balloon

catheters , or the stricture segment acutely

angulated , we used polyethylen e biliary dilators

or V a n Andel dilator (Cook , Inc. , Bloomington , IN) fo r the passage of balloon cathete rs across

the stricture segm en t.

For the extraction of stones , we used several

techniques in addition to conventional technique

using stone baskets (Meditech , W atertown , MA)

(1 ,2,6). A 20F Nelaton rubber tube with multi­

ple side holes was used for saline irrigation and

suction to extract multiple small stones (8). U s­

ing such techniques, we easily extracted or releas­

ed stones in the jejunal lume n through the

a nastom o tic site. AIso , using a ngiographic oc­

clusion b al!oons (Cook , Inc . , Bloomington ,IN) , we successfully retrieved multiple small (but

larger than side hole of Nelaton rubber tube)

stones in bulk. (13) (Fig. 1).

Drain tube was removed after confirming no

댄

in j ejunal loop for removal of residual left in­

trahepatic stones during the operation of rutured

left adrenal cyst (Case 5). In all patients , T-tube

was inserted into j ejunum and its upper limb was

placed in the CBD through anastomotic site . The

findings of T -tube chola ngiography were right

intrahepatic duct stones in five patie nts , left in­

trahepatic duct stones in three patients , and both

in two patients . Among them , seven patients h ad

intrahepatic biliary strictures. Interventional pro­

cedures were p erformed 6 weeks a ft e r the

opera t lOns .

All p atients underwent only local a n esthesia

b y instilling lidocaine into the skin and biliary

tree.

W e introduced interventional instruments into

the j ejunum via T -tube tract and manipulated

in the biliary tree through the anastomotic site.

W e used 9F p이yethylene catheters (which were

angulated according to the individual anatomic

biliary curvature) or visceral angiographic cobra

catheters (Cook , Inc. , Bloomington , IN) for

selecting and opacifying specific biliary duct

Conventional angiographic balloon catheters

(Cook , Inc. , Bloomington , IN) with 5 atm of

maximum pressure were used for the dilatation

of biliary strictures (8-1 3). The diameter of the

b alloon s ranged from 6 to 1 Omm. The balloon

Journal of Korean Radiological Society 1992 ; 28 (5) : 754~ 759

a b c Fig. 1. Stone removal by the occlusion balloon. a. Transjejunal T-tube cholangiogram shows both intrahepatic ductal strictures (arrows) with stones retain­ed behind. b. Multiple Lt. intrahepatic stones are removed in bulk by occlusion balloon (arrow). c. Lt. intrahepatic stones are completely removed.

residual stone on follow-up tubogram.

RESULT

We removed residual intrahepatic biliary

stones successfully by transjejunal T -tube ap­

proach in all cases. Less than five sessions were

required for removal of stones. One or two ses­

sions were required for the dilatation of biliary

strictures followed by less than three sessions of

stone extraction (Table 1)

Follow up tubogram performed 3 days after

the balloon dilatation , showed that the stricture

segment was dilated satisfactorily.

The largest stone was 23mm in diameter. Us­

ing the stone basket , we could deliver the stone

to the jejunallumen through the anastomotic site

without the procedure of crushing. Two days

later , the stone was found in feces (Fig. 2) .

Complications such as nausea or vomiting, oc­

curred not infrequently during and after the pro­

cedures , but were easily controlled with

conservative managemen t. The pain during the

dilatation was usually eliminated by direct in-

stillation of lidocaine into the biliary tree . Mild

post-procedural hemorrhage from biliary tract

was noted , but subsided spontaneously within

2 days.

DISCUSSION

The incidence of biliary stones in Asian coun­

tries is relatively higher than in western coun­

tries because of the high incidence of associated

recurrent pyogenic cholangiohepatitis. Since the

surgical procedures are not satisfactory for in­

trahepatic biliary stones, post-operative per­

cutaneous interventional managements are

indispensable (14)

In cases of large CBD (2 . 5cm or more in

diame ter) , choledocho jejunostomy as drainage

procedure is performed in many hospitals , but

the frequency of residual intrahepatic stones is

still high. In such cases , the major route of in­

tervention has been through the choledocho­

stomy T -tube tract till now (1-3). But the

extraction of residual intrahepatic stones through

- 756-

Byung Hee Lee , et al : Percutaneous Removal of Residual Intrahepatic Stones through Transjejunal T-tube Tract

a b c Fig. 2. Stone removal by the stone basket. a. Transjejunal T-tube cholangiogram shows 23mm stone (arrow) in left intrahepatic duct. b. Stone is entrapped by stone baske t. c. Stone (arrow) is released in jejunal lumen .

conventional choledochostomy T -tube tract is

troblesome and needs much time and m비tiple

sessions due to multifocal intrahepatic biliary

strictures , multiplicity of stores , impacted stones , and the large size of stones

Recently , balloon catheters are applied to

dilatation ofbiliary strictures (1 -6 ,14) . But it re­

mains difficult to extract multiple or large stones , which needs multiple sessions and crushing pro­

cedure (14)

We could solve such problems by per­

cutaneous transjejunal T-tube approach in which

a catheter is inserted into JeJunum during

choledochojejunostomy. Thus we could pass the

large stones into jejunal lumen by the stone

baskets or angiographic occlusion balloons

without the effort of crushing Also we removed

small m비tiple stones in bulk by the use of oc­

clusion balloons

The large balloon has additional effect on

crushing stones or reducing the size of stones .

Especially in case of soft pigmented stones , crushing by the large balloon is simpler and less

injurious than the crusher baskets

This transjejunal T -tube approach can reduce

the number and duration of interventional ses­

sions for crushing large stone and entrapping

each small stones by basket , and can avoid ad­

ditional operations such as attaching j~‘junal seg­

ment extraperitoneally under the abdominal wall

(7). 1n cases of the impacted stone , removal of

stones is possiblc if the polyethylene biliary

dilator can be passed through the stricture seg­

ment along the guide wire. Complete removal

of impacted stones is still difficult , if the guide

wire cannot be passed through the stricture site , because it is impossible to insert p이yethylene

biliary dilator or balloon catheters which is in­

dispensible for stone removal (14) Recently , as the nonoperative methods ,

removal of residual intrahepatic stones via PTBD

tract is tried and shows good results . And en­

doscopy or choledochoscopy via T -tube tract is

now applied.

Also many reports concerning dissolvent or

lithotripsy for intrahepatic biliary stone have

been published (15-21)

U se of methyl tert-butyl ether (MTBE) or

낌

Journal of Korean Radiological Society 1992 ; 28 (5) : 754~ 759

tnonooctanoin as a solvent is very effective

against cholesterol stones . However, those are

ineffective against calcium salt compounds

(b ilirubinate or carbonate) and mixed stones

( 15-17)

Ext raco rporeal shock wave lithotripsy

(ESW L) using piezoelectric lithotripto r can be

applicable in cases with unfavorably located

stones or severe strictures , but it has som e limita­

tions too . It is difficult to target th e intrahepatic

stones especially in the right hepatic lobe due to

rib artifact , and it is expensive and requires more

time (18-21) In summa ry , in case with ch oledochoje­

junostom y , it is more advantageous for res idual

stone extractio n to insert T -tube injejunalloop

ESWL is useful as an adjunct to percutaneous

intervention in selected patients with intrahepatic

stones th at can not be re m oved by means of con­

vent ional percutaneous ext raction technique

REFERENCES

1. Burhenne HJ . Percutaneous extraction of retain­ed bili a ry tract stones : 66 1 patients. AJR 1980;

34:888-898 2 . Burhenne HJ . The techn ique of biliary duct

stone extraction. R adiology 1974 ;11 3:567 -572 3 . Burhenne HJ . T'、Jon-operat ive retained biliary

tract stone ex traction . AJR 1973;1 17:388-398 4. Kerlan R K J r., Pogany C , Goldberg Hl , Ring

EJ. Radio logic intervention in oriental cholangiohepatitis. AJR 1985; 145 :809-813

5. van Sonnenberg E , Casola G , Cubberl y DA , et aL Oriental cholangiohepatit is: diagnostic imag­

in g and interventional managemen t. AJR 1986; 146 :327-33 1

6. ParkJH , Choi Bl , Han MC , et al. Percutaneous rem oval of res idu al intrahepat ic sto nes R adiology 1987;163:619-623

7. Maroney TP , Ring EJ . Percutaneous transje junal catheterization of Roux-en- Y biliary­

j ejunal anastomoses. R adio logy 1987; 164 : 151- 153

8. Martin EC , Karlson KB , Fankuchen El, et al Percutaneous transhepat ic dilation of in-

trahepatic biliary strictures. AJR 1980 ;83 7 -840 9. Salomonowitz E , Castaneda-Zuniga W , Lund

G , et al. Balloon dilatation of benign biliary stric­tures. R adiology 1984;15 1: 163- 166

10. TrambertJJ , Bron KM , Zajko AB , et al. Per­cutaneous transhepatic balloon dilatation of

benign biliary strictures. AJR 1987; 149:945-948 11. Molnar W , Stockum AE . Transhepatic dilata

tion of choledochoenterostomy st ri ctures

R adiology 1987 ;129:59-64

12. Teplick SK , Goldstein R C , Richardson PA , et al. Percutaneous transhepatic choledochoplasty and dilatation of choledochoenterostomy stric­

tures. JMAA 1980 ;244: 1240-1 242 13. Meranze SG , Stein EJ , et al. R emoval of retain

ed com mon bile duct stones with angiographic

occlusion balloons. AJR 1986; 146: 383-385 14. Lee Y , Lee BH , Park JH , Suh C H . Balloon

dilatation of intrahepatic biliary strictures for percutaneous ext raction of residual intrahepatic stones. Cardiovasc Intervent R ad iol 199 1; 14: 102-105

15 ‘ Teplick SK , Haskin PH , Goldstein R C , et a l.

Common bile duct stone dissolution with metyl tert ia ry butyl ether: experience with three pa­

tients. AJR 1987;148: 372-374 16. Haskin PM , Teplick SK , Sammon JK , et al.

Monooctanoin infusion and stone removal

through the transparenchymal tract: use in 17

patients. AJR 1987; 148:185- 188 17. van Sonnenberg E , Casola G , Zakko S, et al.

Gallbladder and bile duct stones : percutaneous therapy with primary MTBE dissolution and

mechanical methods. R ad iology 1988; 169 505-509

18. Burhenne HJ. Biliary lithotripsy: preliminary experience and prospects . Radiology 1988;169 336-337

19. Burhenne HJ , Becker CD , Malone DE , Rawat B, Fache J S. Biliary lithotripsy: early obse rva­tions in 106 pat ients. Rad iology 1989; 171: 363-367

20 . Martin LG , Ambrose SS , Elias DL , Amerson JR. Extracorporeal shock wave lithotripsy of in­trahepatic stones : case presentation and review of the li terature . Am Surg 1988 ;54:3 11 -314

21. Choi BI , H anJK , Park JH , et aL R etained in­trahepatic stones: treatment with piezoelectric

- 758-

Byung Hee Lee , et al : Percutaneous Removal of Residual Intrahepatic Stones through Transjejunal T- tube Tract

lithotripsy combined with stone extraction.

R adio logy 199 1; 178 : 105-1 08

〈국문 요약〉

경공장 T-관도를 통한 경피적 간내 잔류담석 제거술

원자력병원 진단방사선과 · 영동방사선과의원*

이병희 • 이 룡* . 도영수 • 변홍식 • 김기환 · 진수일

지금까지 다량의 담석의 제거를 위하여 총수담관-공장문합술을 시행한 환자들에서 수술 후 간내 잔류담석 제거를

위한 경로로는 총수담관에 삽입된 T-관경로가 이용되어 왔으나 이 경우 큰 담석이나 다수의 협착을 해결하는데는

많은 시간과 노력이 요구되었다.

저자들은 다량의 간내 담도 및 총수담관내의 담석제거를 위하여 총수담관-공장문합술을 시행한 10명의 환자에서

수술시 T관을 공장부위에 삽입토록 요청하여 경피적 공장T관경로를 통하여 전예에서 간내 잔류담석을 완전히 제거

할 수 있었으며， 이러한 경공장 접근법을 이용하여 큰 잔류담석의 경우에도 체외로 제거할 필요없이 단순히 공장내

로 이동시킴으로서 담석을 조각내기위한 과정이나 제거회수를 줄일 수 있었다.

- 759-