Ahmad, M N

Husen, Y H

Jadun, C K

Sheikh, M Y

ul Haq, T

English

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eCommons@AKUDepartment of Radiology Medical College, PakistanMarch 1997Percutaneous removal of biliary stone fromanomalous right hepatic ductT ul HaqAga Khan University, tanveer.haq@aku.eduM Y. SheikhC K. JadunM N. AhmadAga Khan University, nadeem.ahmed@aku.eduY H. HusenFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended Citationul Haq, T., Sheikh, M. Y., Jadun, C. K., Ahmad, M. N., Husen, Y. H. (1997). Percutaneous removal of biliary stone from anomalousright hepatic duct. Journal of Pakistan Medical Association, 47(3), 94-96.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/235Percutaneous Removal of Biliary Stone from Anomalous RightHepatic DuctPages with reference to book, From 94 To 96 Tanveer ul Haq, Mohammed Younus Sheikh, Changes Khan Jadun, M.N. Ahmad, Yousuf H. Husen ( Department ofRadiology, Aga Khan University Hospital, Stadium Road, Karachi. ) IntroductionIntrahepatic biliaiy stone formation is prevalent in East Asia and there is a high frequency of retainedintrahepatic stones after surgical treatment. The etiological factors include orientalcholangiohepatitis1,2, parasitic infections and bile stasis3. If the disease is isolated to one lobe orhepaticsegment, surgical resection may be curative but when the disease is extensive, operative managementincludes a variety of complex drainage procedures. However, even after the biliary-enteric bypasssurgery, symptoms often persist from residual stones and infection. Transcatheter interventionalradiological techniques have been increasingly used in the management of a wide spectrum of biliaiytract disorders. While percutaneous remoyal of common bile duct stones is relatively straight forwani,removal of intrahepatic stones is more complex and requires variable techniques. A case is presentedhere with anomalous insertion of right posterior intrahepatic duct into the cystic duct and havingretained calculus. Percutaneous retrieval of stone was made possible by special technique describedbelow.Case Report A 44 years old female was admitted with right upper quadrant discomfort and fluctuating jaundicesince her cholecystectomy about a year back. Ultrasound showed common bile duct (CBD) stones,confinned by endoscopic retrograde cholangiopancreaticograrn (ERCP) one month earlier. Most CBDstones were removed at ERCP, but some stones were also found in the main intrahepatic ducts (Figure1).This time the patient was admitted for planned surgeiy which was performed with exploration of CBDand choledochoscopy to remove ultra and extra hepatic biliary stones. Peropemlive cholangiogramrevealed clearance of CBD but there was inadequate filling of intrahepatic ducts. Ttube cholangiogramdone two weeks later showed retained stone of about 1 cm size in anomalous right hepatic duct openinginto the cystic duct (Figure 2).Rest of the intra and extra hepatic ducts were clear. Patient was recalled after a month for stoneextraction through the T-tube track. Procedure was done under fluoroscopy with all aseptic precautionsand antibiotic coverage. Patient was given anxiolytic and analgesic before and during the procedure. T-tube was removed and dormia basket was taken into the anomalous duct through the c stic duct. Theanomalous communication was narrow and failed to give way to the stone. Donnia basket was removedand specially curved 5.5F angiographic catheter was then taken into the anomalous duct with the helpof a guide wire. Patient was placed in left lateral position and the stone flushed with normal saline.Stone moved into the left hepatic duct with this maneuver. The catheter was then taken into the lefthepatic duct beyond the stone through the common hepatic duct. Patient was made to sit upright.Flushing through catheter moved the stone into the common hepatic duct (Figure 3)from where it was easily retrieved with the dormia basket with the patient in supine position.Cholangiogram following procedure did not reveal any retained stone in the intra and extra hepaticducts (Figure 4).Follow up till one month was uneventful.Discussion The pathogenesis of the intrahepatic stones could be attributed to gallbladder stones that have migratedupwards. The condition being rare in western countries with some incidence in Asian immigrants, hasbeen found with increasing frequency in east Asia4-6. Oriental cholangiohepatitis being the commonestcause in these countries. Frequently no gallstone found at surgery suggests the intrahepatic origin of thestones. In our case the cause was not obvious, however gallstones were present at the time of surgery.The case was peculiar, since the stone had to be removed from anomalous right hepatic duct.Modifications in usual technique and use of angiographic catheters had made the stone extractionpossible. Reported incidence of bile duct variations is 10-31%7,8. Most conunonbiiaiy ductal anomalyis an anomalous right hepatic duct emptying into the common hepatic duct or cystic duct. Puente andBannura7 reported a prevalence of 4-5% of anomalous right hepatic duct. Koga et al9, have shown noassociation of hepatolithiasis with anatomic variations of main intrahepatic biliaty ducts.Presence of multiple stones in gallbladder and extra heptic ducts in our case indicates other cause ofstone formation like recurrent pyogenic cholangitis and anomalous duct is just a co-incidence.Cholecystectomy and choledochostomy with intrahepatic stone extraction are usually performedbut arenot successful in removing all the intrahepatic stones. Several other surgical procedures are also notsuccessful and the ultimate cure rate by surgery is relatively low, except after segmentectomyorlobectomy for the localized disease. Thus, there is still a high likelihood of residual intrahepaticstones post-operatively. Non- surgical tecimiques are considered to be most appmpriate for removal ofresidual intrahepatic stones. The various options are: extraction through T-tube track, ERCP withsphincterotomy, flexible choledochoscopy and lithotripsy.Percutaneous removal through a T-tube track with a stone basket shows excellent results mostly forCBD stones9, with intrahepatic stones, however, there have beenfew reports of experience10. Park et alhad a 67% success of removing intrahepatic stones via T-tube track11. In conclusion hepatolithiasis is arare disease and percutaneous access in removing these stones is simple with high success rate and lessmorbidity and mortality. Removal of stones from anomalous intrahepatic ducts can also be possiblewhen special maneuver and curved or steerable tips catheters are used.References 1. Wastie, ML. and Canningham LG.E. Roentgenological findings in recurrent pyogenic cholangitis.AIR., 1973;119:71-77.2. Federle, M.P., Cello, JR. Laing, F.C. et al Recurrent pyogenic cholangitis in Asian Immigrants.Radiology, 1982; 143:15 1.156.3. Nakayama, F. Intrahepatic calculi. A special problem in East Asia. World 3. Surg., 1 982;6:802-805.4. akayama, F., Furusana, T. and Nakama, T. Hepatolithiasis in Japan: Present status. Am.J. Surg.,1980;139:216-220.5. Kwon, O.J., Park, Y.H. and Kim, JR A clinical study of cholclithiasis. J. Korean Surg. Soc.,1982;24:1052-1058.6. Ker, C.G., Lee, K.J., Huang, T.J. et at. Intrahepatic gallstones in Taiwan. Southeast Asian J. Surg.,1986,9:42-46.7. Puente, S.G. and Bannura, CC. Radiological anatomy of biliary track: Variations and congenitalabnormalities. World. J. Sung., 1983;7271-276.8. Hamlin, J.A. Biliary ductal anomalies, in operative biliaryradiology Ed Berci, G. Baltimore,Williams and Wilkins, 1981, pp. 110-116.9. Koga, A., Watanabe, S., Takiguch, S. et al. Etiological significance of anatomic variations in themain intrahepatic bile ducts in hepatolithiasis. Acts Radiol., 1987;28:285-288.10. Van-Sonnenberg, E., Casola, C., Cubberley, D.A. et al Oriental cholangiohepatitis. Diagnosticimaging and interventional management. AIR., 1986;146:327-33111. Park, J.H., Choi, HI., Han. M.C. et al Percutaneous removal of residual intrahepatic stones.Radiology, 1987; 163:619-623.

Percutaneous removal of biliary stone from anomalous right hepatic duct

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Percutaneous removal of biliary stone from anomalous right hepatic duct

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