|Year : 2022 | Volume
| Issue : 1 | Page : 27-31
Early experience of percutaneous transhepatic sphincteroplasty with occlusion balloon evacuation of biliary stones in a Lagos, Nigeria Center
Hammed Ninalowo1, Aderemi Oluyemi2, Chidubem Ugwueze3, Samuel Busayo Ogunlade4
1 Interventional Radiology, IRDOC Interventional Radiology Consulting Limited, Euracare Multispecialty Hospital, Victoria Island, Canada
2 Gastronterology, Hepatology and Endoscopy, ReMay Consultancy and Medical Services, Ikeja, Lagos State, Nigeria
3 Diagnostic Radiology, Mount Sinai West - Diagnostic Radiology, New York, USA
4 College of Medicine, Obafemi Awolowo College of Health Sciences, Olabisi Onabanjo University, Ago Iwoye, Ogun State, Nigeria
|Date of Submission||30-Nov-2021|
|Date of Decision||17-Dec-2021|
|Date of Acceptance||24-May-2022|
|Date of Web Publication||07-Jul-2022|
Mount Sinai West - Diagnostic Radiology, New York
Source of Support: None, Conflict of Interest: None
Untreated obstructive jaundice secondary to common bile duct stones can lead to serious metabolic and life threatening complications. Three options exist for CBD stone evacuation; endoscopic retrograde cholangiopancreatography (ERCP), surgical exploration, and percutaneous transhepatic biliary intervention. Open surgical exploration has been the mainstay of management of CBD stones in Nigeria due to limited access to less invasive approaches. The availability of percutaneous transhepatic intervention can serve as an alternative. For this case series, the first consecutive patients who were treated for choledocholithiasis with percutaneous sphincteroplasty between March 2020 and December 2020 at a center in Lagos are described. A total of 6 patients underwent stone evacuation over the study period. The technical success of sphincteroplasty and CBD stone evacuation was 100% in all patients (n = 6) at the first attempt. This series illustrates that percutaneous transhepatic sphincteroplasty for clearance of biliary stones is technically feasible and available to Nigerian patients.
Keywords: Choledocholithiasis, cholelithiasis, common bile duct stone evacuation, external biliary drainage, percutaneous transhepatic sphincteroplasty, plastic biliary stent
|How to cite this article:|
Ninalowo H, Oluyemi A, Ugwueze C, Ogunlade SB. Early experience of percutaneous transhepatic sphincteroplasty with occlusion balloon evacuation of biliary stones in a Lagos, Nigeria Center. J Radiat Med Trop 2022;3:27-31
|How to cite this URL:|
Ninalowo H, Oluyemi A, Ugwueze C, Ogunlade SB. Early experience of percutaneous transhepatic sphincteroplasty with occlusion balloon evacuation of biliary stones in a Lagos, Nigeria Center. J Radiat Med Trop [serial online] 2022 [cited 2022 Oct 6];3:27-31. Available from: http://www.jrmt.org/text.asp?2022/3/1/27/350089
| Introduction|| |
The term “obstructive jaundice” (ObJ) refers to yellowness of the sclera and mucosal membranes caused by hyperbilirubinemia, secondary to intrinsic or extrinsic obstruction of the biliary ductal system. Untreated ObJ can lead to serious metabolic and life-threatening complications, such as nutritional deficits, acute cholangitis, acute renal failure, or hemodynamic instability. Hence, decompression of an obstructed biliary tree is an important and life-saving procedure.
Globally, the most common benign cause of ObJ is common bile duct (CBD) stones (choledocholithiasis).,, Prevalence rates of bile duct stones in the general population in West Africa have not been determined, but hospital-based series suggests that malignant lesions account for the bulk of ObJ presentations.,,, The prevalence of cholelithiasis has been estimated in certain Nigerian populations – 4.4% of Igbos in Nnewi, 17% of Ibadan-based diabetics, and 16% of sickle cell disease patients in Benin have been reported to have gallbladder stones – all these studies being based on the findings on ultrasonography.,,
Three options exist for CBD stone evacuation; endoscopic retrograde cholangiopancreatography (ERCP), surgical exploration (laparoscopy and open approaches), and percutaneous transhepatic biliary intervention. The mainstay of management in Nigeria has been open CBD exploration. Open surgical exploration is utilized due to limited access to less invasive approaches. The recent commencement of ERCP procedures in one of the local teaching hospitals is encouraging. The availability of percutaneous transhepatic intervention can serve as an alternative to the surgical options and their attendant disadvantages. In addition, it can also provide a viable option for patients who had undergone failed endoscopic cannulation.,,
Percutaneous antegrade sphincteroplasty for dislodging CBD stones is a nontraumatic, cost-effective, and clinically safe alternative to endoscopic retrograde sphincterotomy for the same indication.,, Recently, the expertise and capacity for the delivery of this service became available in a private facility in Lagos, Nigeria. This case series aims to document our early experiences with the procedures carried out in this center by an interventional radiologist.
Thus, we hope to demonstrate that percutaneous sphincteroplasty and occlusion balloon for clearance of bile duct calculi are technically feasible in Nigeria as an alternative to surgical open CBD exploration and laparoscopy.
| Methods|| |
For this case series, the first six consecutive patients who were treated for choledocholithiasis with percutaneous sphincteroplasty between March 2020 and December 2020 are described. Radiological diagnosis was confirmed by a review of cross-sectional imaging. Hospital records were then mined for demographic data, clinical consultation notes, relevant additional test results, procedural notes, and follow-up entries.
All cases were performed by the same interventional radiology consultant physician. All patients received preprocedural prophylactic broad-spectrum antibiotics. Four of the cases were performed with the patient under moderate sedation. Two were performed with general anesthesia.
Under ultrasound guidance, a 21-gauge needle was used to access and opacify a peripheral bile duct. An AccuStick set was subsequently advanced into the peripheral duct and a 0.035 wire was advanced into the central bile duct. At this point, the AccuStick is exchanged for a 6Fr sheath. On one occasion (due to a nondilated biliary tree), the gallbladder was accessed with a 21-gauge needle to opacify the biliary tree [Figure 1]. Once the biliary tree was opacified, a second 21-gauge needle was then used to access the peripheral bile duct under fluoroscopic guidance. Subsequent exchange for AccuStick set and 6Fr sheath was identical to other cases.
|Figure 1: Opacifying a nondilated biliary tree by accessing the gallbladder with a 21-gauge needle|
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Through the 6Fr sheath, obstruction in the distal CBD was then successfully crossed with a combination of an angled catheter and glide wire. The glide wire and catheter were advanced into the duodenum past the Sphincter of Oddi More Details. Having placed the catheter in the duodenum, the guidewire was exchanged for a stiff 0.035 wire [Figure 2]. Subsequently, sphincteroplasty was performed with angioplasty balloon catheter, with balloon sizes ranging from 6 mm to 12 mm [Figure 3]. The CBD is then swept using a Fogarty occlusion balloon [Figure 4].
|Figure 2: Stiff 0.035 wire coursing from the biliary tree into the duodenum|
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|Figure 3: Illustration demonstrating percutaneous access of a peripheral duct, crossing of the obstructing stone, and sphincteroplasty at the sphincter of Oddi using an angioplasty balloon (illustration by Dr. Chidubem Ugwueze)|
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|Figure 4: Representation of a Fogarty balloon sweeping the common bile duct to evacuate the stone into the duodenum (illustration by Dr. Chidubem Ugwueze)|
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Finally, a postsphincteroplasty cholangiogram is performed. Findings of the cholangiogram determined the placement of an external/internal biliary drain or a plastic biliary stent [Figure 5]. Success rate and complications associated with the procedure were evaluated.
| Case Summaries|| |
A total of 6 patients (3 males and 3 females) underwent stone evacuation over the study period. The patients' age ranged from 22 to 78 years, with a mean age of 41.6 years (standard deviation = 20.2). All patients presented with jaundice. Pruritus was noted in three of the patients. Two patients presented with recurrent fever, abdominal pains, and icterus, which were indicative of cholangitis/biliary sepsis, but these were treated with antibiotics and resolved by the time the procedure was conducted. Pain in the right upper quadrant was a chief complaint in one of these patients who had had a laparoscopic cholecystectomy carried out 4 months earlier. Two patients had a history of sickle cell disease. [Table 1] summarizes some clinical findings and liver function test deraignment in these individuals.
The technical success of sphincteroplasty and CBD stone evacuation was 100% in all patients (n = 6) at the first attempt. The details of the cases and their intra- and post-operative outcomes are summarized in [Table 2]. The immediate postoperative courses were uneventful, and no major complications such as pancreatitis, perforation, or bleeding were noted. Most patients were discharged home after overnight observation. One patient had abdominal pain a day after the procedure, and emergent computed tomography showed fluid within the pelvis. She underwent ultrasound-guided drainage with bilious fluid aspirated. Thus, a diagnosis of postoperative bile leakage was made. She did well after drainage of the pelvic collection and was discharged home on antibiotics after an overnight admission. Two weeks postprocedure, one patient had a bout of cholangitis which resolved with intravenous antibiotic therapy.
Postsphincteroplasty/evacuation cholangiogram, plastic biliary stents were deployed in five patients and an external/internal biliary stent was placed in one patient before the availability of plastic stents locally. This biliary drain was removed after repeat cholangiogram 2 weeks later. All patients with plastic stents had removed 3 months later by endoscopy with 4 patients having laparoscopic cholecystectomy in the same setting. One patient refused surgery and one patient was a postoperative choledocholithiasis as previously stated.
| Discussion|| |
In the developed world, ERCP is the standard route of evacuating stones in the biliary system., The lack of readily available ERCP and the limited access to laparoscopic surgery means open surgical exploration remain the main alternative available to most patients in Nigeria. The recent availability of percutaneous biliary intervention as an alternative to surgery is certainly a key tool in managing these patients in our population.
In a series of Nigerian patients who underwent open surgical exploration for obstructive CBD stones, the mean hospital stay was 14.4 days (range 5–29 days). This is compared to the 1.3 days (range 1–2 days) for the patients in this series. Although the sample size of this series is too small for general extrapolation to be made, it is important to note the absence of major complications (pancreatitis, bleeding, and perforations) which have been noted to be more prevalent after surgical interventions.
Transhepatic sphincteroplasty is not free of complications. In this case series, one patient had an episode of cholangitis 2 weeks postprocedure which was resolved with antibiotic therapy. Another had transient bile leak 1 day after sphincteroplaty/stone evacuation, but this was successfully managed by percutaneous drainage and necessitated only overnight postdrainage admission. Both these patients have not had any other complaints at 13 and 20 months of follow-up, respectively. A large systematic review of 1347 percutaneous sphincteroplasty patients showed a low complications rate of 1.4% with no cases of postprocedural pancreatitis. Intraprocedural precautions such as the placement of a biliary stent or internal stents with or without external drains are done to mitigate the risks of complications of stricture formation, localized sepsis, or pancreatitis. Postprocedural follow-up is also important to ensure both appropriate recovery from the procedure and to refer the patient for endoscopic retrieval of the plastic biliary stent and interval cholecystectomy.
Additional consideration should be made when selecting patients for sphincteroplasty. In a study of endoscopic papillary large balloon dilation (EPLBD), a stone size greater than 16 mm was an independent predictor of increased rates of adverse events including bleeding. Furthermore, distal CBD stricture was a strong predictive factor for the most serious adverse event, perforation. Although EPLBD is a different mode of stone retrieval, large stone size (>16 mm) and the presence of CBD stricture may be considered relative contraindications for sphincteroplasty.
There are many factors limiting the availability of ERCP in Nigeria and other West African countries. Such barriers include the highly technical nature of the procedure and the steep learning curve for acquiring technical competence. In settings where technical competence is achieved, failure to cannulate the biliary tree can still occur. In both cases, percutaneous access to the biliary tree is an efficacious alternative. Many trained radiologists already place biliary drains in Nigeria primarily with the aid ultrasound. Hence, training radiology practitioners to perform sphincteroplasty with the aid of fluoroscopy could potentially require a much less steep learning curve in comparison to ERCP.
We have shown that percutaneous transhepatic sphincteroplasty and clearance of biliary stones with an occlusion balloon are technically feasible and available to Nigerian patients. More so, there is no need to place an external biliary drain at completion, rather a plastic biliary stent can be placed which can be removed endoscopically in the same setting as surgery. As illustrated in these six patients, the ready availability of an alternative to surgical intervention was the crucial factor.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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