Percutaneous transhepatic sphincterotomy

Endoscopic sphincterotomy (ES) is a highly successful and preferred method for common bile duct (CBD) stone removal. In the rare instance when ES is unsuccessful and CBD stones are removed percutaneously, improved biliary drainage remains desirable to prevent stone recurrence. To this end, percutaneous transhepatic sphincterotomy (PTS) has been performed in nine patients. All patients presented with ascending cholangitis due to biliary obstruction from CBD stones. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy was unsuccessful due to previous upper GI reconstructive surgery (n = 8) and technical failure (n = 1). Percutaneous biliary drainage (PBD), followed by transhepatic stone removal, was performed prior to the transhepatic sphincterotomy using a standard endoscopic papillotome. Fluoroscopic guidance was used in the first three patients and in the remainder both fluoroscopy and percutaneous choledochoscopy were used. Sphincterotomy was successfully performed in all nine patients; post-procedure cholangiograms showed improved biliary drainage. In two patients, the choledochoscope was passed through the sphincter with ease. One patient bled soon after the procedure (fluoroscopic control only) and responded quickly to treatment with blood transfusion. No complications have occurred since choledochoscopy was incorporated into the procedure. All patients remained free of biliary symptoms for an average follow-up of 19 months (range 12-45 months). Our early experience shows that PTS is efficacious in improving biliary drainage and that it offers a therapeutic alternative to surgery in highly-selected patients.