Application of 2-step percutaneous transhepatic choledochoscopic lithotomy in elderly patients diagnosed with complex...

The optimal management of complex intrahepatic and extrahepatic cholelithiasis in very elderly patients with prior abdominal surgery remains challenging. This case series aims to report the application and feasibility of a 2-step percutaneous transhepatic choledochoscopic lithotomy (PTCSL) approach in this high-risk population.

Fourteen patients aged 75 years or older with complex cholelithiasis (widespread or large calculi) and a history of upper abdominal surgery were included.

All patients were diagnosed with complex intrahepatic or extrahepatic cholelithiasis based on imaging findings.

All patients underwent a planned 2-step procedure. The first step involved percutaneous transhepatic cholangial drainage (PTCD) to achieve biliary decompression. The second step consisted of definitive PTCSL for stone removal.

Four (29%) patients admitted for Reynolds' pentad underwent bedside PTCD under ultrasound guidance in an emergency setting. Nine (64%) with a combination of ultrasonography and cholangiography. The interval from the first-step PTCD to the second-step PTCSL ranged from 15 to 96 days (mean, 53.6 days) for all patients. Twelve (86%) patients underwent 1 or 2 surgeries for complete stone removal. All complications were manageable.

This small-scale case series suggests that the 2-step PTCSL approach is a safe and feasible therapeutic alternative for selected elderly and high-risk patients with complex cholelithiasis who are poor candidates for conventional surgery. These preliminary findings warrant further validation in larger prospective studies.