The study was approved by the Ethics Committee of the Second Affiliated Hospital of Shantou University Medical College (Shantou, China).
1. Preparations
<ol>
	<li>Apply strict exclusion criteria to select patients and obtain signed informed consent forms12 (Table 1).</li>
	<li>Apply the following admission criteria:
	<ol>
		<li>Select patients who voluntarily received the two-step PTCSL treatment.</li>
		<li>Select those patients who ...

<ol>
	<li>Shu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+laparoscopic+surgery+for+complex+hepatolithiasis:+a+propensity+score+matching+analysis.">Robotic-assisted laparoscopic surgery for complex hepatolithiasis: a propensity score matching analysis.</a> Surgical Endoscopy. 33 (8), 2539-2547 (2019).</li><li>Korkes, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+treatment+of+complex+biliary+stone+disease+using+endourological+technique+and+literature+review.">Percutaneous treatment of complex biliary stone disease using endourological technique and literature review.</a> Einstein. 13 (4), 611-615 (2015).</li><li>Gamal, E. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+video+choledochoscopic+treatment+of+retained+biliary+stones+via+dilated+t-tube+tract.">Percutaneous video choledochoscopic treatment of retained biliary stones via dilated t-tube tract.</a> Surgical Endoscopy. 15 (5), 473-476 (2001).</li><li>Khalid, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+endoscopic+biliary+exploration+in+complex+biliary+stone+disease:+Case+series+study.">Percutaneous endoscopic biliary exploration in complex biliary stone disease: Case series study.</a> International Journal of Surgery. 24, 73-78 (2020).</li><li>Kim, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+cholangioscopic+treatment+of+patients+with+benign+bilio-enteric+anastomotic+strictures.">Percutaneous transhepatic cholangioscopic treatment of patients with benign bilio-enteric anastomotic strictures.</a> Gastrointestinal Endoscopy. 58 (5), 733-738 (2003).</li><li>Hwang, J. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Risk+factors+for+recurrent+cholangitis+after+initial+hepatolithiasis+treatment.">Risk factors for recurrent cholangitis after initial hepatolithiasis treatment.</a> Journal of Clinical Gastroenterology. 38 (4), 364-367 (2004).</li><li>Bonnel, D. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Common+bile+duct+and+intrahepatic+stones:+results+of+transhepatic+electrohydraulic+lithotripsy+in+50+patients.">Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients.</a> Radiology. 180 (2), 345-348 (1991).</li><li>Kondo, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+clinicopathologic+study+of+primary+cholesterol+hepatolithiasis.">A clinicopathologic study of primary cholesterol hepatolithiasis.</a> Hepato-gastroenterology. 42 (5), 478-486 (1995).</li><li>Williams, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Updated+guideline+on+the+management+of+common+bile+duct+stones+(CBDS).">Updated guideline on the management of common bile duct stones (CBDS).</a> Gut. 66 (5), 765-782 (2017).</li><li>Makuuchi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasonically+guided+cholangiography+and+bile+drainage.">Ultrasonically guided cholangiography and bile drainage.</a> Ultrasound in Medicine &amp; Biology. 10 (5), 617-623 (1984).</li><li>Jeng, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+cholangioscopy+in+the+treatment+of+complicated+intrahepatic+biliary+strictures+and+hepatolithiasis+with+internal+metallic+stent.">Percutaneous transhepatic cholangioscopy in the treatment of complicated intrahepatic biliary strictures and hepatolithiasis with internal metallic stent.</a> Surgical Laparoscopy. 10 (5), 278-283 (2000).</li><li>Zhuo, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+choledochoscopic+lithotomy+(PTCSL)+is+effective+for+the+treatment+of+intrahepatic+and+extrahepatic+choledocholithiasis.">Percutaneous transhepatic choledochoscopic lithotomy (PTCSL) is effective for the treatment of intrahepatic and extrahepatic choledocholithiasis.</a> Surgical Laparoscopy, Endoscopy &amp; Percutaneous Techniques. 31 (3), 326-330 (2020).</li><li>Hazey, J. W., McCreary, M., Guy, G., Melvin, W. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+percutaneous+treatment+of+biliary+tract+calculi+using+the+holmium:+YAG+laser.">Efficacy of percutaneous treatment of biliary tract calculi using the holmium: YAG laser.</a> Surgical Endoscopy. 21 (7), 1180-1183 (2007).</li><li>Ozturk, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+surgical+technique+applied+with+urological+instruments+in+bilobar+multiple+hepatolithiasis:+Ultra-mini+percutaneous+hepatolithotomy.">New surgical technique applied with urological instruments in bilobar multiple hepatolithiasis: Ultra-mini percutaneous hepatolithotomy.</a> Turkish Journal of Urology. 43 (3), 371-377 (2017).</li><li>Ozcan, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+transhepatic+removal+of+bile+duct+stones:+results+of+261+patients.">Percutaneous transhepatic removal of bile duct stones: results of 261 patients.</a> Cardiovascular and Interventional Radiology. 35 (3), 621-627 (2012).</li><li>Kint, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+treatment+of+common+bile+duct+stones:+results+and+complications+in+110+consecutive+patients.">Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients.</a> Digestive Surgery. 32 (1), 9-15 (2015).</li><li>Yeh, Y. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+trans-hepatic+cholangioscopy+and+lithotripsy+in+the+treatment+of+intrahepatic+stones:+a+study+with+5+year+follow-up.">Percutaneous trans-hepatic cholangioscopy and lithotripsy in the treatment of intrahepatic stones: a study with 5 year follow-up.</a> Gastrointestinal Endoscopy. 42 (1), 13-18 (1995).</li><li>Jan, Y. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+trans-hepatic+cholangioscopic+lithotomy+for+hepatolithiasis:+long-term+results.">Percutaneous trans-hepatic cholangioscopic lithotomy for hepatolithiasis: long-term results.</a> Chang Gung Medical Journal. 17 (1), 149 (1994).</li><li>Cheon, Y. K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+long-term+results+and+recurrent+factors+after+operative+and+nonoperative+treatment+for+hepatolithiasis.">Evaluation of long-term results and recurrent factors after operative and nonoperative treatment for hepatolithiasis.</a> Surgery. 146 (5), 843-853 (2009).</li><li>Tsutsumi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparative+evaluation+of+treatment+methods+for+bile+duct+stones+after+hepaticojejunostomy+between+percutaneous+transhepatic+cholangioscopy+and+peroral,+short+double-balloon+enteroscopy.">A comparative evaluation of treatment methods for bile duct stones after hepaticojejunostomy between percutaneous transhepatic cholangioscopy and peroral, short double-balloon enteroscopy.</a> Therapeutic Advances in Gastroenterology. 10 (1), 54-67 (2017).</li></ol>

The authors have no conflicts of interest to disclose.

Intrahepatic and extrahepatic choledocholithiasis contribute to biliary obstruction, and the associated cholangitis could lead to gram-negative endotoxemia with clinical manifestations of septic shock or multiorgan dysfunction. Thus, biliary stones represent a complex disease that can be challenging for surgeons, especially in cases of patients who have had previous complex abdominal surgeries or patients with abnormal anatomical structure. PTCSL is being widely used around the world, but there remains a need for innovat...

Intrahepatic and extrahepatic choledocholithiasis is a complex medical problem faced by surgeons and is very common in East Asian countries1. At present, surgical intervention is required for most choledocholithiasis, while the main treatments for bile duct stones include open surgery, percutaneous transhepatic choledochoscopic lithotomy (PTCSL), laparoscopic lithotomy2, percutaneous endoscopic biliary exploration3,4, and endoscopic retrograde cholangiopancreatography. However, patients with bilioenteric anastomosis or Billroth II reconstruction, with an abnormal anatomical structure such as a duodenal periampullary diverticulum, which makes the biliary duct difficult to access through an endoscopic approach5,6,7,8, or who have had previous complex abdominal surgeries, including partial gastrectomy, could not undergo endoscopic therapy or laparoscopic lithotomy. Endoscopic therapy may also not be suitable for hepatolithiasis with large and impacted stones. Therefore, PTCSL, in general, may be a better choice9.
The traditional PTCS approach follows such a procedure to expand the sinus gradually and perform percutaneous transhepatic biliary drainage10,11, which requires a relatively long hospitalization cycle, usually between 2 and 3 weeks, leading to the potential for biliary fistula, biliary tract infection, bleeding, and peritonitis, with multiple expanding sheath sizes. The procedure is composed of two parts. In the first step, the target bile duct is punctured, and the guide wire is inserted while observing the bile outflow. Then, a dilator is used to slowly expand the channel along the guide wire. After the channel is successfully established, the dilator is pulled out, a drain is placed into the target bile duct, and the guide wire is pulled out.
The percutaneous liver puncture and drainage (PTCD) is complete if the bile drainage is unobstructed and the drain is fixed without blood outflow. The sinus tract becomes stable 1 week after PTCD, when it can then be expanded. The guide wire is placed into the drain tube and expanded through the sinus tract along the guide wire with a 10F dilator, and finally placed into a 10F drain. The sinus tract is expanded once a week after surgery, with a 2F size increase each time, so that the sinus tract can be expanded to 16F at 4 weeks after PTCD. In the second step, after expansion of the sinus tract to 16F, the surgery to remove the stone is performed using a biliary fiber lens. Therefore, the traditional PTCSL described above requires a treatment cycle and contributes to high economic pressure for the patients. Moreover, low stone extraction efficiency and repeated and multiple surgical procedures for stone removal are also inevitable disadvantages of traditional PTCS, which limits the use of this technology.
From January 2013, we began to apply PTCS for the minimally invasive treatment of patients with complex intrahepatic and extrahepatic choledocholithiasis in our hospital but modified some key steps of traditional PTCS. In the first step, the surgery was performed at 1 week after PTCD, just when the sinus tract became stable, and the sinus was expanded to 16F directly, using a 16F expander which greatly reduced the preoperative preparation time. In the second step, different from the traditional technology, a Wolf nephroscope was used instead of a traditional choledochoscope to perform the operation, which we refer to as the &#34;two-step PTCSL method.&#34; To determine whether the PTCSL procedure was safe, minimally invasive, and efficient, this study retrospectively reviewed 81 patients with intrahepatic and extrahepatic choledocholithiasis treated by the two-step PTCSL method from January 2013 to January 2020.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.9% Normal saline solution</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>16-F series fascia dilator</td>
			<td></td>
			<td>type PLVW, Cook Medical</td>
			<td></td>
		</tr>
		<tr>
			<td>adjustable pressure pump</td>
			<td></td>
			<td>type APL; Guangzhou Jielun Medical Equipment Co. , Ltd, Guangdong Province, China</td>
			<td></td>
		</tr>
		<tr>
			<td>biliary balloon dilator</td>
			<td></td>
			<td>ATB advance; Cook Medical</td>
			<td></td>
		</tr>
		<tr>
			<td>blade</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>camera system</td>
			<td></td>
			<td>1088i HD Camera Control Unit, PAL 220 V; Stryker Corporation</td>
			<td></td>
		</tr>
		<tr>
			<td>Cavity mirror protective sleeve</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>clamp</td>
			<td></td>
			<td>5Fr, Richard Wolf GmbH, Germany</td>
			<td></td>
		</tr>
		<tr>
			<td>color ultrasound machine</td>
			<td></td>
			<td>DC-N2S, Mindray</td>
			<td></td>
		</tr>
		<tr>
			<td>Cook net basket</td>
			<td></td>
			<td>NGE-017115-MB, COOK Medical Inc. , Bloomington, USA</td>
			<td></td>
		</tr>
		<tr>
			<td>drainage pack</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>expander</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>guide wire</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>hydroelectric lithotripter</td>
			<td></td>
			<td>Aymed Medical, <img alt="Equation 1" src="/files/ftp_upload/63206/63206eq01.jpg" style="margin: auto;" />stanbul, Turkey</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;Iodophor</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>&#160;Kidney basin</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>light source</td>
			<td></td>
			<td>Voice-control compatible X8000 Xenon Light Source of 300 W;Stryker Corporation, MI</td>
			<td></td>
		</tr>
		<tr>
			<td>Medical syringe</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>puncture needle</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>suction apparatus</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>surgical gauze</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>trocar</td>
			<td></td>
			<td>-</td>
			<td></td>
		</tr>
		<tr>
			<td>Wolf nephroscope</td>
			<td></td>
			<td>12-degree Ultra-Wide-Angle Ureteroreno-scope; Richard Wolf GmbH, Germany</td>
			<td></td>
		</tr>
		<tr>
			<td>zebra guide wire</td>
			<td></td>
			<td>type HAW; Cook Medical, Bloomington, IN</td>
			<td></td>
		</tr>
	</tbody>
</table>

a two-step method for percutaneous transhepatic choledochoscopic lithotomy

Intrahepatic and extrahepatic choledocholithiasis is a challenge in the field of biliary surgery. We present our experience using a two-step percutaneous transhepatic choledochoscopic lithotomy (PTCSL) procedure to treat challenging biliary stones. We retrospectively reviewed 81 patients with intrahepatic and extrahepatic choledocholithiasis treated using this two-step PTCSL from January 2013 to January 2020, including 40 males and 41 females, with an average age of 66 years. In contrast to traditional percutaneous transhepatic cholangioscopy (PTCS), a channel was established directly through a 16F Amplatz sheath, and the stone in the channel was removed with the aid of a nephroscope. The clinical efficacy and complications of all patients were analyzed. Eighty-one patients (81/81, 100%) had their biliary stones successfully removed; 62/81 patients (76.5%) had biliary stones completely removed after the first operation; 17/81 patients (21%) underwent a second operation; 2/81 patients (2.5%) needed a third operation to completely remove the stones. The incidence of severe bleeding during the operation was 0%, and there were no deaths. The use of the two-step PTCSL method is safe and efficacious, and contributes to a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

All patients had their biliary tract stones cleared successfully, with 58 patients (58/81, 72%) having bile duct stones completely removed after the first operation, 18 patients (18/81, 22%) requiring a second operation, and five patients (5/81, 6%) undergoing a third operation to completely remove the stones. Three patients had recurrent intrahepatic cholelithiasis in the 5th and 6th postoperative years. There were 56 patients (56/81, 68.7%) who underwent percutaneous liver surgery, as well as 25 p...

Watch this Scientific Journal Video about A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy at JoVE.com

A Two-Step Method for Percutaneous Transhepatic Choledochoscopic Lithotomy

This "two-step method" significantly improved the success rate of percutaneous transhepatic choledochoscopy and achieved a better prognosis of intrahepatic and extrahepatic choledocholithiasis.

Intrahepatic and extrahepatic choledocholithiasis is a challenge in the field of biliary surgery. We present our experience using a two-step percutaneous ...

This protocol significantly improves the success rate of percutaneous transhepatic choledochoscopy and achieves a better prognosis of intrahepatic and extrahepatic choledocholithiasis. This technique reduces the recurrence of intrahepatic and extrahepatic choledocholithiasis and shortens the whole lithotripsy period, operation time, and the distance between skin entrance sites and targeted biliary ducts. PTCSL can be a better choice for the treatment of complex intrahepatic and extrahepatic choledocholithiasis, such as in patients who had undergone previous complicated abdominal surgery or who had anatomical abnormalities and were unable to undergo an endoscopic examination.This technique can also be used for percutaneous nephrolithotomy to manage kidney stone problems. The structure of the intrahepatic bile duct is complex and vulnerable to injury, which raises the surgical risk, and the visual demonstration can better avoid these dangerous complications. One week before the operation, perform the procedure for percutaneous transhepatic cholangio drainage, or PTCD.Insert an indwelling 8F biliary drainage tube to drain and reduce the swelling of the bile duct. Wait for the sinus tract to become stable at one week after this procedure. Inject 20 milliliters of saline into the bile duct along the drainage tube.After a guide wire is inserted into it, pull out the PTCD tube. To place the fascia dilator in sheath, expand the sinus using a 16F expander and join a 16F belt dilator so that the 16F sheath can reach the bile duct where the stone might have been placed. Locate the stones.Use clamping forceps to break and remove the stones. Wash out small stones and powdered stones using an adjustable pressure pump. At the end of the procedure, leave a drainage tube inside the patient for one week.Using PTCSL, all patients had their biliary tract stones cleared successfully. 72%of the patients had the bile duct stones completely removed after the first operation, while 28%of the patients required more than one operation. 56 patients underwent percutaneous liver surgery and 25 patients underwent surgery by indwelling a sinus formed by a T tube.The number of stones was equal to one in 70 patients. The average hospital stay was 11 days. There was a complication of a small amount of reactive pleural effusion.Minor intraoperative biliary bleeding was observed in two patients, and one patient had a biliary infection after surgery. However, no massive hemorrhaging of the biliary tract was observed. Preoperative ultrasound was used to accurately locate the stone location and to retain the 8F drain, and the sinus was directly expanded using a 16F expander.

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2.2K Görüntüleme.  Shantou University Medical College. Bu protokol perkütan transhepatik koledokoskopinin başarı oranını önemli ölçüde artırır ve intrahepatik ve ekstrahepatik koledokolitiyazisin daha iyi bir prognozunu sağlar. Bu teknik, intrahepatik ve ekstrahepatik koledokolitiyazisin nüksetmesini azaltır ve tüm litotripsi süresini, ameliyat süresini ve cilt giriş bölgeleri ile hedeflenen safra yolları arasındaki mesafeyi kısaltır. PTCSL, daha önce komplike karın cerrahisi geçirmiş veya anatomik anormallikleri olan v...