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Video Presentation - 4
Vacuum assisted (clearpetra) miniaturized percutaneous hepatolithotripsy for complex intrahepatic stones in a high-risk pediatric patient
Ali Sezer 1, Ali Ekber Hakalmaz 2, Şenol Emre 2
1 Division of Pediatric Urology, Department of Pediatric Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
2 Department of Pediatric Surgery, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, Turkey
Introduction
Intrahepatic stone disease remains challenging in patients with altered biliary anatomy and portal hypertension. Conventional surgical or endoscopic options often carry high risk. We present a novel percutaneous approach utilizing a pre-existing bronchobiliary fistula tract for safe and effective stone removal in a high-risk adolescent patient.
Video Method and Findings:
A 17-year-old female with a history of bronchobiliary fistula repair, cholecystoenterostomy, and hepaticojejunostomy developed recurrent intrahepatic stones and biliary dilatation. Conventional re-intervention was contraindicated due to extensive prior surgery and portal hypertension. Imaging revealed a dilated, blind-ended bronchobiliary fistula tract from the left hepatic duct, which was used for percutaneous access, avoiding a new transhepatic puncture.
A two-stage approach was employed. First, a percutaneous transhepatic catheter (PTK) was inserted via the fistula tract, allowing decompression and tract maturation. Several weeks later, percutaneous lithotripsy was performed. After tract dilation to 14 Fr, a ClearPetra suction-assisted access sheath was inserted. A 12 Fr nephroscope was advanced for visualization, and stones were fragmented using both Holmium:YAG laser and pneumatic lithotripter. Continuous low-pressure suction (max 120 mmHg) was applied using a vacuum device connected to the sheath, enabling active removal of fragments and minimizing intrabiliary pressure. A 7.5 Fr flexible ureteroscope confirmed complete clearance, including distal branches. The total fluoroscopy exposure was under two minutes. An 8 Fr PTK was placed postoperatively and removed on day five. No complications occurred.
Conclusion
This novel, suction-assisted percutaneous approach using a repurposed urological sheath allowed safe and complete intrahepatic stone removal via a pre-existing fistula tract, avoiding complications of conventional methods. It may be a valuable alternative in complex hepatobiliary cases with altered anatomy and portal hypertension.