SIR 2024
Gastrointestinal Interventions
Omid Shearkhani, MD
Clinical Fellow
University of Toronto, Canada
Financial relationships: Full list of relationships is listed on the CME information page.
Neeral Patel, MD
Clinical Fellow
Joint Department of Medical Imaging, Canada
Disclosure information not submitted.
Aliya Gulamhusein, MD
Staff Physician
University Health Network, Canada
Disclosure information not submitted.
Eran Shlomovitz, MD FACS
Surgeon Interventional Radiologist
Toronto General Hospital, Canada
Disclosure information not submitted.
(1) To provide an image-rich case-based review of percutaneous transhepatic cholangioscopy (PTCS) as a minimally invasive treatment option in management of stones and improving bile flow in patients with biliary atresia (BA) post-Kasai procedure. (2) To share a pictorial review of a stepwise approach, procedural steps, tips, and techniques. (3) To discuss indications for PTCS in treatment of biliary stone disease in patients with BA.
Background:
Biliary atresia (BA) is a progressive, idiopathic, inflammatory process which affects the biliary tree {1}, resulting in obliteration of the biliary tree, obstruction of bile flow, and consequently progressive liver damage. If BA is confirmed, a Kasai procedure (hepatoportoenterostomy) should be performed promptly {2} to restore bile flow from the liver to the proximal small bowel. In patients with BA, pre-emptive liver transplant is generally avoided due to advantages of transplanting later in life {2}. Delaying requirement for transplantation necessitates optimal management and minimization of complications in the pre-transplant period. The major complication in BA patients after Kasai procedure is symptomatic biliary strictures and stones resulting in cholangitis {3}.
Clinical Findings/Procedure Details:
Interventional treatment of biliary stones can be divided into endoscopic and percutaneous categories {4}. After Kasai procedure, which alters native anatomy, conventional endoscopic interventions can be highly challenging. Percutaneous transhepatic cholangioscopy (PTCS) {5} may be of considerable utility in management of stones and improving bile flow in patients with BA post-Kasai procedure.
In this educational exhibit, we present our institutional experience with PTCS in successful removal of biliary stones in three patients with BA and prior Kasai procedure, who had suffered from biliary stone disease causing both severe pain and cholangitis. Pre- and post-procedural images along with clinical outcomes and follow-ups are shared in this exhibit. A pictorial review of a stepwise approach and procedural steps will be provided. Procedural techniques including hardware utilized, methods of stone removal (both fluoroscopic and endoscopic), along with pre- and post-procedural management techniques will also be discussed.
Conclusion and/or Teaching Points:
Biliary stone extraction via PTCS can serve as a minimally invasive treatment option in improving bile flow in patients with BA post-Kasai procedure. In this way it may be an underutilized bridging procedure for patients awaiting liver transplantation.