Intraductal biliary stones can result in significant acute and long-term complications. When patients' anatomy precludes more traditional management, the interventional radiologist may be called upon to provide well-established techniques for percutaneous biliary drainage and stone removal. This can be particularly challenging when the patient has excessively mobile, impacted, large or multiple stones. Percutaneous biliary endoscopy with adjunct interventional techniques can successfully treat these patients avoiding the patient dreaded "tube for life" scenario. Direct percutaneous visualization of the biliary tree can also diagnose and provide symptomatic relief for stone-mimicking pathologic conditions such as biliary tumors. This article will review the role, technique, and considerations for percutaneous biliary endoscopy and adjunct interventions in patients with isolated and complex, biliary stone disease and stone-mimicking pathologies.

Interventional radiologists are commonly called upon to manage patients with benign and malignant ureteral pathologic conditions. Unfortunately, treatments for both cure and palliation can be fraught with problems causing patients to be undesirably maintained with lifelong catheters. This review describes outcomes for antegrade and retrograde therapeutic options and techniques for patients with most types of ureteral pathologic conditions that the interventional radiologist would encounter in practice.

Learning ObjectivesTo review the role of percutaneous transhepatic endoscopy and holmium laser lithotripsy in the treatment of intraductal biliary stones.BackgroundMany patients with choledocholithiasis suffer from cholangitis and obstructive symptoms. Traditionally, these are addressed with ERCP but there are many patients who are not candidates for ERCP due to prior enteric bypass. In addition, many patients have large stones or a large number of stones which make removal via traditional fluoroscopic techniques dificult. For these patients, percutaneous transhepatic endoscopy with holmium laser lithotripsy represents an effective treatment option.Clinical Findings/Procedure DetailsThis Educational Exhibit will provide a detailed review of the technique used for percutaneous transhepatic endoscopy with holmium laser lithotripsy. To summarize, these patients first require percutaneous biliary access, diagnostic cholangiography, and placement of a 12F internal-external biliary drainage catheter. This catheter should remain in place for at least 4 weeks to allow for well-formed percutaneous tract. At the time of endoscopy, the biliary catheter is exchanged for a 12F peel-away sheath to allow for low pressure endoscopy using a 7.5F ureteroscope. Under direct visualization, holmium laser lithotripsy is then performed for larger stones supplemented with use of a stone basket. At our institution, this is done in partnership with an endourologist. This procedure can often result in single session stone removal. Complications potentially include hemobilia, cholangitis with sepsis, and ductal perforation.Conclusion and/or Teaching PointsIn conclusion, percutaneous transhepatic endoscopy with holmium laser lithotripsy is an effective treatment for biliary stones in patients who are not candidates for traditional ERCP or have an extensive stone burden. This represents an opportunity for IR since much of the procedure is based on standard catheter and guidewire technique within the intrahepatic biliary ducts. This exhibit will help interventional radiologists consider this technique either alone or in partnership with endourology, or other physicians experienced wtih the use of small endoscopes, to treat this difficult patient population. Learning ObjectivesTo review the role of percutaneous transhepatic endoscopy and holmium laser lithotripsy in the treatment of intraductal biliary stones. To review the role of percutaneous transhepatic endoscopy and holmium laser lithotripsy in the treatment of intraductal biliary stones. BackgroundMany patients with choledocholithiasis suffer from cholangitis and obstructive symptoms. Traditionally, these are addressed with ERCP but there are many patients who are not candidates for ERCP due to prior enteric bypass. In addition, many patients have large stones or a large number of stones which make removal via traditional fluoroscopic techniques dificult. For these patients, percutaneous transhepatic endoscopy with holmium laser lithotripsy represents an effective treatment option. Many patients with choledocholithiasis suffer from cholangitis and obstructive symptoms. Traditionally, these are addressed with ERCP but there are many patients who are not candidates for ERCP due to prior enteric bypass. In addition, many patients have large stones or a large number of stones which make removal via traditional fluoroscopic techniques dificult. For these patients, percutaneous transhepatic endoscopy with holmium laser lithotripsy represents an effective treatment option. Clinical Findings/Procedure DetailsThis Educational Exhibit will provide a detailed review of the technique used for percutaneous transhepatic endoscopy with holmium laser lithotripsy. To summarize, these patients first require percutaneous biliary access, diagnostic cholangiography, and placement of a 12F internal-external biliary drainage catheter. This catheter should remain in place for at least 4 weeks to allow for well-formed percutaneous tract. At the time of endoscopy, the biliary catheter is exchanged for a 12F peel-away sheath to allow for low pressure endoscopy using a 7.5F ureteroscope. Under direct visualization, holmium laser lithotripsy is then performed for larger stones supplemented with use of a stone basket. At our institution, this is done in partnership with an endourologist. This procedure can often result in single session stone removal. Complications potentially include hemobilia, cholangitis with sepsis, and ductal perforation. This Educational Exhibit will provide a detailed review of the technique used for percutaneous transhepatic endoscopy with holmium laser lithotripsy. To summarize, these patients first require percutaneous biliary access, diagnostic cholangiography, and placement of a 12F internal-external biliary drainage catheter. This catheter should remain in place for at least 4 weeks to allow for well-formed percutaneous tract. At the time of endoscopy, the biliary catheter is exchanged for a 12F peel-away sheath to allow for low pressure endoscopy using a 7.5F ureteroscope. Under direct visualization, holmium laser lithotripsy is then performed for larger stones supplemented with use of a stone basket. At our institution, this is done in partnership with an endourologist. This procedure can often result in single session stone removal. Complications potentially include hemobilia, cholangitis with sepsis, and ductal perforation. Conclusion and/or Teaching PointsIn conclusion, percutaneous transhepatic endoscopy with holmium laser lithotripsy is an effective treatment for biliary stones in patients who are not candidates for traditional ERCP or have an extensive stone burden. This represents an opportunity for IR since much of the procedure is based on standard catheter and guidewire technique within the intrahepatic biliary ducts. This exhibit will help interventional radiologists consider this technique either alone or in partnership with endourology, or other physicians experienced wtih the use of small endoscopes, to treat this difficult patient population. In conclusion, percutaneous transhepatic endoscopy with holmium laser lithotripsy is an effective treatment for biliary stones in patients who are not candidates for traditional ERCP or have an extensive stone burden. This represents an opportunity for IR since much of the procedure is based on standard catheter and guidewire technique within the intrahepatic biliary ducts. This exhibit will help interventional radiologists consider this technique either alone or in partnership with endourology, or other physicians experienced wtih the use of small endoscopes, to treat this difficult patient population.