Successful shock-wave lithotripsy of bile duct stones using ultrasound guidance

Extracorporeal shockwave lithotripsy for common bile duct stones

BACKGROUND

Successful extraction of common bile duct stones after endoscopic sphincterotomy may be achieved in 86-96 per cent of cases. However, some stones are too large to be removed in this manner. This study looks at the role of extracorporeal shock-wave lithotripsy to break up common bile duct stones as an adjunct to sphincterotomy in patients with stones greater than 10 mm in size.

METHODS

Twenty-seven patients with large (10-35 mm) common bile duct stones were treated with piezoelectric generated extracorporeal shock-wave lithotripsy (ESWL) following failed stone extraction after endoscopic sphincterotomy (ES). The stones were visualized ultrasonographically and a piezolith 2300 Wolf lithotripter used to administer the shockwaves.

RESULTS

Visualized stone fragmentation was reported in 20 of 48 sessions. Clearance of targeted stones was achieved in 18 of the 27 patients, but actual duct clearance was demonstrated in only 17 of the 27. There were few adverse effects and mortality was nil.

CONCLUSION

This study concludes that ESWL following failed ES is a useful additional treatment option for very large bile duct stones, but should only be used after surgical risk and past history of biliary disease have been carefully reviewed and found to contraindicate conventional surgical management. An algorithm of treatment options for common bile duct stones is presented.

Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones: report on 117 patients

BACKGROUND

Endoscopic sphincterotomy and stone extraction can clear the bile ducts in 85% to 90% of patients. In case endoscopic stone extraction fails, insertion of a biliary endoprosthesis is an alternative.

METHODS

Biliary endoprostheses were inserted in 117 patients (73 women and 44 men, median age 80 years). Follow-up was achieved by contacting referring physicians and general practitioners.

RESULTS

Biliary drainage was established in all patients. Early complications occurred in 10 patients (9%) with a fatal outcome in 1. In 59 patients the endoprosthesis was a temporary measure before elective surgery or repeat endoscopy. Further treatment in these 59 patients caused only mild complications and there were no deaths. Endoprostheses were inserted as permanent therapy in 58 patients. Median follow-up in these 58 patients was 36 months (range, 1 to 117 months). A total of 34 complications occurred in 23 patients (40%), cholangitis being the most frequent. During follow-up, 44 patients died, 9 as a result of a biliary-related cause.

CONCLUSIONS

These data favor temporary use of biliary endoprostheses in patients with endoscopically irretrievable bile duct stones. However, as a permanent therapy, late complications occur in many patients and the risk increases proportionally in time. Therefore, permanent biliary stenting should preferably be restricted to patients unfit for elective treatment at a later stage and with a short life expectancy.

Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones. A prospective randomized trial

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Current role of extracorporeal shockwave therapy in surgery

In urology the introduction of extracorporeal shockwave therapy brought a revolutionary change to the management of urinary calculi. This inspired the introduction of shockwave therapy in several fields of surgery; it has been applied as a potential alternative to several operative procedures but is still experimental. So far, the major application of shockwave therapy has been lithotripsy of stones in the gallbladder, common bile duct, pancreatic duct and salivary gland ducts. Other applications are in the non-operative management of bone healing disturbances and in the inhibition of tumour growth. Steps towards selective thrombus ablation and pretreatment of heavily calcified arteries have also been made. In this review, the applications of extracorporeal shockwave therapy in several areas of surgery are discussed. It is concluded that, for selected patients, shockwave treatment may serve as a useful addition to the surgical armamentarium.

Biliary lithotripsy with a new electromagnetic shock wave source. A 2-year clinical experience

During a two-year study period 170 consecutive patients with gallbladder stones, suitable for lithotripsy, were treated with a new electromagnetic lithotriptor (Modulith) and oral bile acids; 142 patients were treated as outpatients. Sufficient fragmentation were obtained in 94% when 2112 +/- 137 shocks in 211 sessions with an energy setting of 17.8 +/- 0.8 kV were administered. Only 4/170 patients needed transient analgesia. Overall, side effects were transient and mild, but three patients developed biliary pancreatitis, which was treated by endoscopic sphincterotomy in two of them. A total of 67/100 patients were free of stones after one year. Subgroup analysis showed that 80% of the patients (stone diameter 5-20 mm), 64% (20-30 mm) and 65% (multiple stones), respectively, can expected to be free of stones after 12 months. In addition, 25 patients with large, endoscopically not extractable common bile duct stones were treated by lithotripsy with the Modulith. After endoscopic placement of a nasobiliary tube, stone targeting was possible by ultrasonography in 14 patients and by fluoroscopy in another 11 cases. In 23 of the 25 patients (92%) stone clearance by endoscopy was achieved after application of 2516 +/- 565 shocks with an energy preset of 18 kV. One patient refused further endoscopic procedures after successful fragmentation and another required local stone dissolution therapy. Side effects occurred more frequently (P < 0.05) after lithotripsy of bile duct stones than of gallbladder stones, but they were without major clinical relevance. The new lithotriptor Modulith thus enables safe and highly effective lithotripsy of gallbladder calculi on an outpatient basis.(ABSTRACT TRUNCATED AT 250 WORDS)

Lithotripsy in the treatment of biliary stones

Noninvasive or minimally invasive techniques for the treatment of biliary stones have been significantly advanced in the past two decades. The least invasive, extracorporeal shock-wave lithotripsy, continues to be used successfully, not only at its earliest reported site of use in Munich, Germany, but also in numerous other centers in the world. Lithotriptors that utilize a spark gap electrode or other sources of energy to generate sound waves and imaging by radiographic and ultrasonographic targeting of stones have proved to be effective in fragmenting biliary stones (90% to 95%) that are too large or otherwise inaccessible to removal by endoscopic papillotomy. Stone clearance (53% to 90%) may require successive treatments and the removal of debris by transendoscopic or surgical means. The mortality is low (0.5%), and the post-treatment course is relatively uncomplicated in an elderly, high-risk group of patients.

Non-surgical management of bile duct stones refractory to routine endoscopic measures

Endoscopic sphincterotomy and percutaneous approaches to the biliary tract have revolutionized the treatment of bile duct stones. Both the endoscopic and transhepatic approaches are less invasive than open surgery. This is an advantage for the mostly elderly and frail patients with common bile duct stones. Other patients with intrahepatic stones, e.g. young patients with oriental lithiasis, may also profit from the non-surgical approach. In this latter group it is often difficult for the surgeon to obtain access to the stone-bearing bile ducts. Due to the anatomical situation, size or impaction of stones the non-surgical approach, including mechanical disintegration, may primarily fail. Several techniques such as intracorporeal lithotripsy using electrohydraulic probes or laser light, extracorporeal shockwave lithotripsy or direct contact dissolution are now available and often allow complete clearance of the bile ducts. If a kidney lithotripter with radiographic devices is available, it should be used after an attempt at mechanical lithotripsy has failed (Figure 1). According to the literature, experience with this method is greater than with any other 'third-step approach'. The procedure is simple, relatively safe and successful in approximately 80% of patients. However, in at least one third of patients, several sessions have to be performed and further endoscopy is frequently required for extraction of fragments. Intracorporeal techniques may become the procedure of choice in the future, at least in patients with common bile duct stones. At the moment, however, the different devices are still not fully developed and too susceptible to damage. A further major drawback, especially with high-energy electrohydraulic intracorporeal lithotripsy, is the danger of bile duct injury or even perforation, so that most procedures must be performed under optical control. The use of contact dissolution cannot generally be recommended. Treatment with mono-octanoin or modified mono-octanoin solvents takes too long, is often not successful and has a high rate of side-effects. MTBE may shorten the procedure considerably, but is suitable only for cholesterol stones, and the danger of spill-over into the intestine with absorption and systemic side-effects has to be weighed against the probability of success.