PTEHL Cleared Bile Duct Stones in 80+ Patients

Key Takeaways

• At a single center, patients aged 80 years and older undergoing PTEHL for intrahepatic and/or extrahepatic bile duct stones had complete clearance in 72% and near-complete clearance in 28%.
• Most treatment courses were completed in one session, with 96% finished after a single PTEHL session and 4% requiring a second session.
• Adverse events occurred in 26% of patients and were mostly minor, with one biliopleural fistula requiring drainage.
• The report describes cholangitis and combined intrahepatic plus extrahepatic stones as significant in multivariable analysis.

Clearing complex biliary stones in very elderly patients can be difficult when general anesthesia, standard endoscopic access, or surgery may be less suitable, especially when cholangitis, large stones, or combined intrahepatic and extrahepatic disease are present. Percutaneous transhepatic endoscopic holmium laser lithotripsy (PTEHL) was evaluated in this setting at a specialized center in Hanoi, Vietnam.

In the Phan et al PTEHL study in patients aged 80 years and older with bile duct stones, investigators retrospectively reviewed cases treated from January 1, 2023, through December 30, 2024, with records accessed on February 1, 2025. Of 582 total PTEHL cases, 62 patients were age-eligible and 50 were included. Patients were selected through multidisciplinary discussion among PTEHL, endoscopic retrograde cholangiopancreatography (ERCP), or surgery, with PTEHL considered for cholangitis after prior biliary drainage, major comorbidity that precluded general anesthesia, combined intrahepatic plus extrahepatic stones, or common bile duct stones larger than 15 mm. The procedure used percutaneous biliary access with cholangioscopy-guided holmium laser lithotripsy under local anesthesia with intravenous sedation and monitored anesthesia care, and technical success meant either complete clearance or only residual stones smaller than 5 mm in peripheral branches without further stone-removal treatment.

Most PTEHL procedures were completed in one session, with only two patients requiring a second treatment. All patients met the study's technical success definition without additional intervention or surgery, including 36 of 50 with complete clearance and 14 of 50 with near-complete clearance. No patient underwent subsequent surgery or another stone-removal procedure.

Adverse events occurred in 26% of patients and were mostly minor, with hemobilia described as the most common minor event and one moderate biliopleural fistula requiring drainage. No procedure-related mortality was reported. Mean hospital stay was 14.8 ± 8.0 days overall and was longer with cholangitis than without it (17.6 ± 8.0 vs 10.6 ± 5.7 days; p = 0.001), although the study counted stay from initial biliary drainage in two-stage cases and from lithotripsy in single-stage cases. Multivariable analysis identified cholangitis and combined intrahepatic plus extrahepatic stone location as factors associated with stone-clearance outcome. The stone-location estimate was reported as OR 12.65, 95% CI 1.21–125.00; p = 0.034.

The authors described these findings as a specialized single-center experience with a retrospective design, no control group, and a small sample. They also noted that the multivariable model may be overfit and that the wide confidence interval around the stone-location estimate suggests imprecision. Follow-up was short, so stone recurrence and late complications were not assessed, and the report remains focused on short-term procedural outcomes.

The authors concluded that PTEHL was a feasible minimally invasive option in this elderly cohort, while emphasizing that comparative studies against ERCP or surgery are still needed.

Clinician Questions

Which older patients were selected for PTEHL in this bile duct stone cohort?

Patients in this series were aged 80 years or older with intrahepatic and/or extrahepatic bile duct stones and an indication for PTEHL, selected through multidisciplinary discussion when they had cholangitis after prior biliary drainage, major comorbidity precluding general anesthesia, combined intrahepatic plus extrahepatic stones, or common bile duct stones larger than 15 mm.

How was near-complete stone clearance defined after PTEHL for biliary stones?

Near-complete clearance meant residual stones smaller than 5 mm confined to peripheral bile duct branches distal to the subsegmental ducts, with no residual stones in larger ducts and no need for additional stone-removal treatment, which is why these cases still counted toward the technical success endpoint.

What follow-up findings were reported after catheter removal in elderly patients treated with PTEHL?

Drainage catheters were removed after 2 to 3 weeks following follow-up imaging; removal was successful in all patients, and no biliary-related readmission was reported during 3 months of follow-up.