Removal of common bile duct stones by the combination of percutaneous balloon dilatation and extracorporeal shock-wave lithotripsy

Analysis of Wire-Guided Hemostasis Introducer for Percutaneous Therapy of Bile Duct Stones

BACKGROUND

Bile duct stones (BDS) are usually removed via endoscopic retrograde cholangiopancreatography (ERCP) or, if ERCP remains unsuccessful, percutaneous transhepatic cholangiodrainage (PTCD). However, PTCD provides limited access to large BDSs. We analyzed a modified approach of PTCD for percutaneous therapy of BDS.

METHODS

We used a modified approach of PTCD with a 13-french (Fr) hemostasis introducer for transhepatic access to BDS. Short-wired balloon or basket catheter were applied for safe removal of BDS. Patient characteristics, effectiveness, and complications were analyzed.

RESULTS

We identified 11 patients who underwent PTCD with hemostasis introducer. BDSs were either pushed forward to the duodenum (36%) or both partly pushed and extracted via hemostasis introducer (64%). In some cases, mechanical lithotripsy was necessary (45%). Complete removal of BDS was initially achieved in 36% of patients, 45% received additional PTCD, and in 19% stent implantation was performed. Finally, all BDSs could be removed. Laboratory analysis revealed significant reduction of alkaline phosphatase (p = 0.03) and C reactive protein (p = 0.03). Complications occurred only in 1 patient with post-interventional cholangitis.

CONCLUSION

Our study showed feasibility and safety of a modified PTCD with hemostasis introducer. In addition, protection of liver tissue from sharp-edged catheters and stones was achieved. Therefore, our modification revealed an innovational approach for transhepatic removal of BDS.

Endoscopic balloon sphincter dilation (sphincteroplasty) versus sphincterotomy for common bile duct stones

BACKGROUND

Endoscopic balloon dilation was introduced as an alternative to endoscopic sphincterotomy to preserve the sphincter of Oddi and avoid undesirable effects due to an incompetent sphincter. Endoscopic balloon dilation has been largely abandoned by USA endoscopists due to increased risks of pancreatitis noted in one multicentre trial, but is still practiced in parts of Asia and Europe.

OBJECTIVES

To assess the beneficial and harmful effects of endoscopic balloon dilation versus endoscopic sphincterotomy in the management of common bile duct stones.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, and EMBASE until January 2004. We hand searched Gastrointestinal Endoscopy (1983-2002), read through bibliographies of all included randomised clinical trials, and contacted all primary authors regarding missed randomised trials.

SELECTION CRITERIA

Randomised clinical trials comparing endoscopic balloon dilation versus endoscopic sphincterotomy in removal of common bile duct stones irrespective of publication status, language, or blinding.

DATA COLLECTION AND ANALYSIS

Data collection was done by two independent authors for decisions on study inclusion, data abstraction, and quality assessment. When there was a non-resolvable discrepancy, the third author made the final decision. Analysis was run with RevMan Analysis.

MAIN RESULTS

Fifteen randomised trials met our inclusion criteria (1768 participants). Less than half of the trials reported adequate methods of randomisation and only two trials used blinded outcome assessment. Endoscopic balloon dilation is statistically less successful for stone removal (relative risk (RR) 0.90, 95% confidence interval (CI) 0.84 to 0.97), requires higher rates of mechanical lithotripsy (RR 1.34, 95% CI 1.08 to 1.66), and carries a higher risk of pancreatitis (RR 1.96, 95% CI 1.34 to 2.89). Conversely, endoscopic balloon dilation has statistically significant lower rates of bleeding. When a fixed-effect model is applied endoscopic balloon dilation leads to significantly less short-term infection and long-term infection. There was no statistically significant difference with regards to mortality, perforation, or total short-term complications.

AUTHORS' CONCLUSIONS

Endoscopic balloon dilation is slightly less successful than endoscopic sphincterotomy in stone extraction and more risky regarding pancreatitis. However, endoscopic balloon dilation seems to have a clinical role in patients who have coagulopathy, who are at risk for infection, and possibly in those who are older.

The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy

BACKGROUND

When choledochoscopic lithotomy with basket and electrohydraulic lithotripsy is used to remove intrahepatic duct stones, fragments or small stones usually remain in the bile duct that are too small to be captured with a basket.

METHODS

An attempt was made to remove stone fragments in 16 patients with intrahepatic duct stones by antegrade balloon dilation of the sphincter of Oddi with a conventional balloon catheter. After balloon dilation, remnant stones and sludge were pushed through the papilla with the choledochoscope.

RESULTS

Bile duct stones were completely removed in 12 of 16 patients (75%); stones were removed in 1 session. There was no clinical evidence of procedure-related pancreatitis or fatal complications.

CONCLUSIONS

Percutaneous transhepatic papillary balloon dilation of the sphincter of Oddi and clearance of remnant bile duct stones and stone fragments with the tip of choledochoscope is simple and effective in patients undergoing percutaneous transhepatic choledochoscopic lithotomy.

Effectiveness and safety of balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi

OBJECTIVE

The purpose of this study was to describe a technique for percutaneous bile duct stone clearance by pushing the stones into the small bowel after balloon dilation of the papilla.

SUBJECTS AND METHODS

During a 2-year period, 38 patients were treated percutaneously for stones in the biliary tree. Twenty-one patients were treated through a T tube or transcystic tract. Seventeen patients were treated through a transhepatic tract. Twenty-three patients had one stone each. Eight patients had two stones, and seven patients had three or more calculi. Stone size ranged from 3 to 16 mm in diameter (mean size, 6.7 nm). Balloon diameter based on the transverse diameter of the stones ranged from 7 to 18 mm (mean, 6.7 mm). An 11.5-mm occlusion balloon was used for pushing the stones through a 7- to 9-French vascular introducer. A catheter was left in the common bile duct from 1 to 6 days for external drainage.

RESULTS

The technique was successfully used for clearance of stones in 36 (94.7%) of the 38 patients. With 29 patients, the procedure was performed with only one attempt. Two attempts were necessary for five patients, and three attempts were necessary for four patients. Two major complications were cholangitis and biliary pleural effusion. No deaths were related to the procedure.

CONCLUSION

Percutaneous bile duct stone clearance by dilation of the papilla and evacuation of the stones in an antegrade fashion with an occlusion balloon is a safe and effective technique. It can be an alternative to basketing stones in selected patients.

Balloon dilatation of the sphincter of Oddi facilitates passage of glass beads from the canine biliary tract

Laparoscopic management of common duct stones is increasing. The most widely used technique involves trans-cystic duct scope placement and stone extraction. Occasionally, stones cannot be retrieved and are allowed to pass spontaneously after manipulation of the sphincter of Oddi. This study examines a model of sphincter of Oddi dilatation in the dog to facilitate passage of glass beads simulating gallstones. In 24 dogs, glass beads of varying sizes (3-8 mm) were implanted in the gallbladder and allowed to pass spontaneously over 1 month. In three separate groups, these animals underwent (1) sham instrumentation of the sphincter of Oddi (control), (2) sphincter dilatation with balloon catheters, or (3) transduodenal sphincterotomy. At the end of 1 month, all the animals were autopsied, and the glass beads were retrieved. Histologic sections of the pancreas were examined for possible pancreatitis. The results of this study show that no animal experienced pancreatitis from sphincter manipulation or the passage of glass beads. The control animals who underwent sham manipulation of the sphincter passed 10% of their glass beads. In contrast, after sphincter dilatation, 52.5% of the 3-mm glass beads passed or 22% of all size beads. Animals with sphincterotomy passed a similar amount of glass beads as those with balloon dilatation. These studies suggest that balloon dilatation is as efficacious as sphincterotomy in facilitating the passage of glass beads from the canine biliary tract.

Alternative methods in the management of bile duct stones

Common bile duct stones may now be dealt with, in most cases, without the need for surgery. To be sure, surgery continues to remain the gold standard for duct clearance and treatment of biliary sepsis. Improvements in endoscopic and radiologic technology and methodology have permitted excellent access to the biliary tree by the transduodenal and transhepatic approaches. In the majority of patients, total duct clearance and excellent drainage can be accomplished, averting sepsis and the need for open surgery.

Fragmentation of bile duct stones by extracorporeal shock-wave lithotripsy: a five-year experience

Over 5 yr, 103 elderly patients (mean age = 70 yr) with bile duct stones (mainly not amenable to endoscopic extraction) underwent adjuvant extracorporeal shock-wave lithotripsy using a first-generation kidney lithotripter. Disintegration of stones was achieved after a mean of 1.4 sessions in 92% of the patients. Spontaneous passage of fragments into the duodenum occurred in one fourth of the patients, and endoscopic extraction of fragments was necessary in 75% of the patients, resulting in complete clearance of the bile duct stones in 91 (88%) of 103 patients. The most important adverse effect was septic disease after extracorporeal shock-wave lithotripsy in 4% of the patients. The 30-day mortality rate was 1% (one patient), and another 15 patients died during a mean follow-up of 26 +/- 14 mo (mainly of causes unrelated to biliary tract disease). Two of 91 patients who had been rendered stone free were readmitted because of recurrent stone disease during the follow-up period. Of the 43 patients who still had their gallbladders during extracorporeal shock-wave lithotripsy, 14% subsequently underwent cholecystectomy. These data show that extracorporeal shock-wave lithotripsy of bile duct stones is a useful and safe adjunct to nonsurgical procedures for the removal of calculi in the biliary tree.

Extracorporeal shock wave treatment of common bile duct stones: experience with two different lithotriptors at a single institution

Extracorporeal shock wave lithotripsy (ESWL) is a new treatment modality for retained common bile duct stones. Sixty-two patients (mean age 75 years, range 27-95 years) with retained common bile duct stones were treated with two different lithotriptors. One of the lithotriptors operated on the electrohydraulic principle (Dornier HM-3) (n = 13), the other on the electromagnetic principle (Siemens Lithostar) (n = 49). All HM-3 patients were treated under general anaesthesia, whereas with the Lithostar one patients was treated under general anaesthesia, 43 received analgesia and sedation and five had no analgesia at all. Patients treated with the Lithostar had more sessions (mean 1.9 versus 1.3, P less than 0.05) and needed more stock waves (mean 8611 versus 2534, P less than 0.001) than patients treated with the HM-3. Fragmentation was achieved in all patients treated with the HM-3 and in 42 (86 per cent) patients treated with the Lithostar. In this latter group ten patients underwent common bile duct exploration without complications. Eleven patients had transient haematuria after treatment with the HM-3 and two patients (one in each group) had a subcapsular haematoma of the right kidney, all without clinical sequelae. At follow-up (median: HM-3 43 months, Lithostar 18 months), none of the patients had biliary complaints. We conclude that ESWL of retained common bile duct stones in safe and effective with both lithotriptors and should be considered before surgery in the elderly or high-risk patient.

Retained bile duct stones in a patient with Billroth II gastrectomy: extracorporeal shock wave lithotripsy and papillary dilatation via T tube

A postoperative T tube cholangiogram after cholecystectomy in a 62 year old patient showed two retained calculi of 14 mm diameter each. Endoscopic sphincterotomy was not possible because of previous Billroth II gastrectomy. The stones were disintegrated by electromagnetically generated extracorporeal shock waves. The T tube was replaced by a balloon catheter and the papilla of Vater was dilatated allowing passage of stone fragments. We conclude that retained bile duct stones can be removed without sphincterotomy or percutaneous extraction by extracorporeal shock wave lithotripsy and papillary dilatation. This method should be considered especially in patients with Billroth II gastrectomy.