Rationale: 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. Patient concerns: Fourteen patients aged 75 years or older with complex cholelithiasis (widespread or large calculi) and a history of upper abdominal surgery were included. Diagnoses: All patients were diagnosed with complex intrahepatic or extrahepatic cholelithiasis based on imaging findings. Interventions: 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. Outcomes: 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. Lessons: 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.
Liu et al. (Fri,) studied this question.