To evaluate the safety and efficacy of percutaneous transhepatic choledochoscopic lithotripsy (PTCSL) in the treatment of hepatolithiasis under the concept of enhanced recovery after surgery (ERAS).

Clinical data of 35 patients with hepatolithiasis undergoing PTCSL in Lingnan Hospital of the Third Affiliated Hospital of Sun Yat-sen University from January 2016 to December 2020 were retrospectively analyzed. Among them, 11 patients were male and24 female, aged from 39 to 89 years, with a median age of 61 years. 32 patients had a history of biliary tract surgery in which 13 cases had more than twice surgeries. 9 patients were initially diagnosed with stones and 26 cases of recurrent stones. The informed consents of all patients were obtained and the local ethical committee approval was received. ERAS management measures were delivered during perioperative period, and one-stage or two-stage PTCSL was employed. Postoperative recovery and incidence of complications were observed. Postoperative pain was assessed by visual analogue scale (VAS).

All patients underwent PTCSL successfully, including 19 cases of one-stage and 17 cases of two-stage PTCSL. 8 patients underwent more than twice PTCSL, and 3 cases received PTCSL combined with T-tube lithotomy. 26 cases underwent PTCSL via the right approach and 10 cases via the left approach. The average operation time was (2.3±1.1) h,the amount of water consumption was (6 300±575) ml, the median intraoperative blood loss was 40(5-400) ml,the postoperative VAS score was 2.9±1.0, and the length of hospital stay was 12(6-27) d. No intraoperative death was reported. Postoperative complications occurred in 9 cases, including 3 cases of perihepatic effusion,2 cases of pleural effusion, 2 cases of biliary tract infection and 1 case of bile leakage, and all were improved after corresponding treatments. Intraoperative bile duct bleeding occurred in 1 case, who was found with bile duct portal vein fistula in segment Ⅲ by postoperative reexamination. The patient was relieved by ablation after noneffective conservative interventions. The complete stone clearance rate was 89%(31/35). No residual stone was found in the secondary branch of bile duct by CT scan.

Under the concept of ERAS, PTCSL is a minimally invasive, safe and feasible treatment for hepatolithiasis, which can accelerate postoperative recovery, especially for patients with recurrent or residual biliary tract stones.