Treatment of difficult intrahepatic stones by using extracorporeal and intracorporeal lithotripsy techniques: 10 years' experience in 55 patients

Evidence-based clinical practice guidelines for cholelithiasis 2021

The Japanese Society of Gastroenterology first published evidence-based clinical practice guidelines for cholelithiasis in 2010, followed by a revision in 2016. Currently, the revised third edition was published to reflect recent evidence on the diagnosis, treatment, and prognosis of cholelithiasis conforming to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Following this revision, the present English version of the guidelines was updated and published herein. The clinical questions (CQ) in the previous version were reviewed and rearranged into three newly divided categories: background questions (BQ) dealing with basic background knowledge, CQ, and future research questions (FRQ), which refer to issues that require further accumulation of evidence. Finally, 52 questions (29 BQs, 19 CQs, and 4 FRQs) were adopted to cover the epidemiology, pathogenesis, diagnosis, treatment, complications, and prognosis. Based on a literature search using MEDLINE, Cochrane Library, and Igaku Chuo Zasshi databases for the period between 1983 and August 2019, along with a manual search of new information reported over the past 5 years, the level of evidence was evaluated for each CQ. The strengths of recommendations were determined using the Delphi method by the committee members considering the body of evidence, including benefits and harms, patient preference, and cost-benefit balance. A comprehensive flowchart was prepared for the diagnosis and treatment of gallbladder stones, common bile duct stones, and intrahepatic stones, respectively. The current revised guidelines are expected to be of great assistance to gastroenterologists and general physicians in making decisions on contemporary clinical management for cholelithiasis patients.

Management of Hepatolithiasis: Review of the Literature

PURPOSE OF REVIEW

Hepatolithiasis is a disease characterized by intrahepatic stone formation. In this article, we review the features of this disease and explore the established and emerging treatment modalities.

RECENT FINDINGS

Recent reports show an increasing prevalence of hepatolithiasis, likely owed to increased immigration and shifts in the Western diet. New pharmacotherapy options are limited and are often only supportive. Endoscopic intervention still cruxes on removal of impacted stones, though new techniques such as bile duct exploratory lithotomy and lithotripsy continue to advance management. Although hepatectomy of the effected portion of the liver offers definitive therapy, alternative less invasive modalities such as combined endoscopic/interventional radiology modalities have been utilized in select patients. Additionally, liver transplant serves as an option for otherwise incurable hepatolithiasis with coexisting liver dysfunction. Multiple emerging pharmacologic and procedural interventions may provide novel treatment for hepatolithiasis. While definitive therapy remains resection of affected liver segments, these modalities offer hope for less invasive approaches in the future.

Recurrent pyogenic cholangitis: a review of imaging findings and clinical management

Recurrent pyogenic cholangitis (RPC) is an infective process involving the biliary tree typified by pigmented intraductal calculi with dilatation of the intra- and extrahepatic biliary tree. Previously endemic to South-east Asia, RPC can now be seen in Western countries with the increasing access to international travel and immigration. Affected patients are often plagued by recurrent bouts of cholangitis, and commonly suffer from complications such as abscess formation and biliary strictures. In severe cases, cirrhosis with portal hypertension may develop. The disease is also a known risk factor for cholangiocarcinoma, and can be seen in up to 5% of affected patients. Its exact etiology is unknown, but parasitic infections such as Clonorchis sinensis and Ascaris lumbricoides, ascending bacterial infection with gut flora (Escherichia coli) and low socioeconomic status have been associated strongly with it. This paper reviews the imaging features of the disease, as well as the roles of interventional radiology and surgery with respect to management of the condition.

Double-balloon enteroscopy for choledochojejunal anastomotic stenosis after hepato-biliary-pancreatic operation

BACKGROUND AND AIM

There have been few reports on the success rate of balloon dilation and stent deployment using endoscopic retrograde cholangiopancreatography by double-balloon enteroscopy (DBE-ERCP) or on the follow-up period after stent removal in patients with a reconstructed digestive tract and stenosis of choledochojejunal anastomosis. The present study was designed to evaluate the usefulness of DBE-ERCP in patients with a reconstructed digestive tract and stenosis of choledochojejunal anastomosis.

METHODS

Forty-four patients with stenosis of choledochojejunal anastomosis underwent DBE-ERCP at Okayama University Hospital between April 2008 and January 2012 (107 procedures). Rates of reaching choledochojejunal anastomosis, stent deployment, and restenosis after stent removal were retrospectively evaluated.

RESULTS

Insertion of DBE into the choledochojejunal anastomotic site succeeded in 38 of 44 patients (86.4%), and anastomotic dilation and stent deployment succeeded in 36 of 44 patients (81.8%). In 32 of 44 patients (72.7%), their anastomotic stenoses were improved, and they achieved stent removal. After stent removal, restenosis of choledochojejunal anastomosis was detected in seven of 32 patients; however, the resolution of restenosis was achieved in all seven of those patients.

CONCLUSION

Dilation of choledochojejunal anastomosis combined with stent deployment using DBE-ERCP seems to be a viable first-line treatment for patients with stenosis of choledochojejunal anastomosis.

Clearance of refractory bile duct stones with Extracorporeal Shockwave Lithotripsy: higher failure rate in obese patients

OBJECTIVE

Bile duct stones that cannot be removed endoscopically are still a challenge in interventional gastroenterology. Extracorporeal shockwave lithotripsy (ESWL) with subsequent endoscopic extraction of residual fragments is an established treatment option if other endoscopic means are not successful. Our study aimed to investigate the efficacy and safety of ESWL for clearance of refractory bile duct stones.

MATERIAL AND METHODS

A total of 73 consecutive patients treated for refractory choledocholithiasis with ESWL were retrospectively analyzed. Success and complication rates were calculated.

RESULTS

Complete stone clearance was achieved in 66 cases (90%). Patients with complete clearance had a significantly lower body mass index or BMI (25.55 ± 5.01 kg/m² vs. 31.60 ± 6.26 kg/m², p = 0.035) and needed less ESWL treatments (3.61 ± 1.87 vs. 5.00 ± 1.63, p = 0.048). A relevant drop of hemoglobin occurred significantly more often in the group with partial clearance (43% vs. 6%, p = 0.005).

CONCLUSIONS

ESWL proves to be an excellent clearing approach to refractory bile duct stones with high success rates. However, obesity is one risk factor for ESWL failure and higher procedural hazard.

ESWL for difficult bile duct stones: A 15-year single centre experience

AIM: To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) for the management of refractory bile duct cholelithiasis in a third level referral centre.

METHODS: The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus, SIEMENS) from October 1990 to April 2005 were evaluated. All patients were monitored during the procedure and antibiotics were administered in case of cholangitis. The χ² test and logistic regression analysis were performed as appropriate.

RESULTS: Two hundred and fourteen patients (102 males, 112 females; mean age 74.8 ± 0.84 years - single stone 97, multiple stones 117) underwent ESWL. The mean number of sessions and shock waves were 3.5 ± 0.13 and 3477.06 ± 66.17, respectively. The maximum stone size was 5 cm. Complete stone clearance was achieved in 192 (89.7%) patients. Of the remaining patients 15 required surgery, 2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance. Age, sex and stone characteristics were not related to treatment outcome. Major complications occurred in two patients (haemobilia and rectal bleeding) and minor complications in 25 (3 vomiting, 22 arrhythmias). No procedure-related deaths occurred.

CONCLUSION: ESWL is a safe and effective technique for clearance of refractory bile duct stones.

Choledochoscopy-assisted intraductal shock wave lithotripsy

In more than 90% of choledocholithiasis cases, endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction are successful therapeutic options for clearance of the bile duct with the use of a stone retrieval balloon or basket. However, these techniques fail in a small percentage of patients with biliary stones, and advanced techniques for fragmentation must be used. Intraductal shock wave lithotripsy offers the endoscopist a therapeutic option that may be effective despite the difficulties of a large, impacted stone that cannot be captured by a basket, or a stricture that prohibits delivery of a stone beyond it. This article reviews the use of electrohydraulic lithotripsy and laser lithotripsy in the clinical setting.

Nonsurgical management of an impacted mechanical lithotriptor with fractured traction wires: endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy

In a patient with a mid-common bile duct stone, the traction wires of a mechanical lithotriptor snapped, resulting in lithotriptor basket impaction. Simultaneous occurrence of these two potential complications of endoscopic stone extraction is very rarely reported. Extracorporeal shock wave lithotripsy failed to fragment the stone entrapped within the impacted basket. Endoscopic intracorporeal electrohydraulic shock wave lithotripsy successfully fragmented the stone under direct visualization through a cholangioscope. The entrapped stone within the basket could subsequently be pulled into the supra-ampullary bile duct for the final fragmentation with an extra-endoscopic mechanical lithotriptor cable. The present report is the first to describe a safe and effective use of endoscopic intracorporeal electrohydraulic shock wave lithotripsy followed by extra-endoscopic mechanical lithotripsy in the management of an impacted lithotriptor basket.

Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers

INTRODUCTION

PD and common bile duct (CBD) stones often require mechanical lithotripsy (ML) at ERCP for successful extraction. The frequency and spectrum of complications is not well described in the literature.

AIM

To describe the frequency and spectrum of complications of ML.

METHODS

A comprehensive retrospective review of cases requiring ML of large or resistant PC and/or CBD stones using a 46-point data questionnaire on type(s) of complication, treatment attempted, and success of treatment. The study involved 7 tertiary referral centers with 712 ML cases (643 biliary and 69 pancreatic).

RESULTS

Overall incidence of complications were: 4-4% (31/712); 23/643 biliary, 8/69 pancreatic; 21 single, 10 multiple. Biliary complications: trapped (TR)/broken (BR) basket (N = 11), wire fracture (FX) (N = 8), broken (BR) handle (N = 7), perforation/duct injury (N = 3). Pancreatic complications: TR/BR basket (N = 7), wire FX (N = 4), BR handle (N = 5), pancreatic duct leak (N = 1). Endoscopic intervention successfully treated complications in 29/31 cases (93.5%). Biliary group treatments: sphincterotomy (ES) extension (N = 7), electrohydraulic lithotripsy (EHL) (N = 11), stent (N = 3), per-oral Soehendra lithotripsy (N = 8), surgery (N = 1), extracorporeal lithotripsy (N = 5), and dislodge stones/change basket (N = 4). Pancreatic group treatments: ES extension (N = 3), EHL (N = 2), stent (N = 5), Soehendra lithotriptor (N = 4), dislodge stones/change basket (N = 2), extracorporeal lithotripsy (ECL) (N = 1), surgery (N = 1). Perforated viscus patient died at 30 days.

CONCLUSION

The majority of ML in expert centers involved the bile duct. The complication rate of pancreatic ML is threefold greater than biliary lithotripsy. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most frequently utilized treatment options.

Piezoelectric extracorporeal shockwave lithotripsy for bile duct stone formation after choledochal cyst excision

We report a case of bile duct stones in which piezoelectric extracorporeal shockwave lithotripsy (ESWL) was highly effective for the clearance of stones. A 16-year-old girl, who had undergone excision of a choledochal cyst when she was 3 years old, presented a spiking fever and colic abdominal pain. Radiological investigations showed two large stones incarcerating to the proximal end of hepatico-jejunostomy anastomosis. Massive debris was also present in intrahepatic bile duct proximal to the anastomosis. She underwent piezoelectric ESWL with an EDAP LT02 lithotripter. An average of 40 min ESWL session was repeated at intervals of 2 or 3 days. Neither anesthetic nor sedative treatment was required. By the end of the sixth session, the stones incarcerated were fragmented and the debris in the intrahepatic bile duct was completely eliminated. We conclude that piezoelectric ESWL is a less invasive, effective and repeatable method, therefore, it could be a treatment of choice for bile duct stone formation after choledochal cyst excision.

Extracorporeal shock wave lithotripsy for clearance of refractory bile duct stones

BACKGROUND AND STUDY AIMS

Following endoscopic sphincterotomy, 90% of bile duct stones can be removed with a Dormia basket or balloon catheter. The removal can fail in patients with large stones, intrahepatic stones, bile duct strictures or a difficult anatomy. The aim of this retrospective study is to investigate the efficacy and safety of extracorporeal shock wave lithotripsy in fragmenting and allowing the extraction of bile duct stones that could not be cleared by routine endoscopic means including mechanical lithotripsy.

PATIENTS AND METHODS

From 1989 to January 2005, we treated with extracorporeal shock wave lithotripsy 376 patients (133 males and 243 females, median age 71.4 years) with bile duct stones that were not removable following endoscopic sphincterotomy, using the extracorporeal shock wave lithotripsy Lithostar Plus machine built by Siemens Co. of Erlangen, Germany. Stone targeting was performed fluoroscopically following injection of contrast via nasobiliary drain or T-tube in 362 patients and by ultrasonography in eight patients. Residual fragments were cleared at endoscopic retrograde cholangiopancreatograhy. Two hundred and ten of the 370 patients treated (56.7%) showed only 1 stone, 57 (15.4%) showed 2, 45 (12.1%) showed 3, 58 (15.6%) showed more than 3 stones. The median diameter of the stones was 21mm (range 7-80mm).

RESULTS

Complete stone clearance was achieved in 334 of the 376 patients who underwent the extracorporeal shock wave lithotripsy procedure (90.2%). Six patients (1.5%) dropped out of treatment during their first sessions, mainly because of intolerance. Each patient averaged 3.7 treatments (1-12), at an average rate of 3470 shocks per session (1500-5400), at an average energy level of 3.4mJ (1-7). Complications were recorded in 34 patients (9.1%); 22 patients experienced symptomatic cardiac arrhythmia, 4 haemobilia, 2 cholangitis, 3 haematuria, 3 dyspnoea; no deaths were associated with the procedure.

CONCLUSIONS

Extracorporeal shock wave lithotripsy is a safe and effective therapy in those patients in whom endoscopic techniques have failed with a clearing rate of 90.2% of refractory bile duct stones with a low rate of complications.

The treatment of intrahepatic calculosis by applying helix hydro-jet lithotripsy under video choledochoscope: a report of 30 cases

BACKGROUND AND AIMS

Intrahepatic lithiasis is a common disease in southeast Asia [Sheen-Chen and Chou, Acta Chir Scand 156:387-390, 1990], and a difficult problem of biliary surgery. There is no established method of treating patients with intrahepatic stones [Uchiyama et al., Arch Surg 137:149-533, 2002]. In recent years, resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection. The need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate [Andersson et al., HPB Surg 2:145-147, 1990; Adamek et al., Scand J Gastroenterol 34:1157-1161, 1999]. Hepatic resection only fit the cases in which the stones localized in one lobe or segment, while it doesn't fit the cases which have polystones in left and right biliary tract. Duodenoscope can only get the stones in the common bile duct and cannot deal with the intrahepatic lithiasis. The management of intrahepatic lithiasis can only be treated by intraoperative or postoperative choledochoscope. For big stones or compact stones, lithotripsy should be applied. But the laser lithotripsy and the electrohydraulic lithotripsy can cause serious complications such as perforation of bile duct. It needs a safer and more reliable treatment for intrahepatic lithiasis. The aim of our work is to study the lithotrity treatment of intrahepatic lithiasis by using helix hydro-jet under Video Choledochoscope.

MATERIALS AND METHODS

From March 31, 2003 to October 20, 2004, 30 intrahepatic stone patients were treated. Eighteen of them were women and 12 were men, with ages ranging from 35 to 80 years (mean, 58 years). According to B ultrasound and computed tomography (CT) scan report, there were five cases of intrahepatic lithiasis and common bile duct stones, 25 cases of left and right hepatic duct stones, and one case with giant intrahepatic stone (1.5 x 1.5 x 1.2 cm). Intraoperative or postoperative choledochoscopic helix hydro-jet lithotripsy was applied through a video choledochoscope. For the patients to have the intraoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by B ultrasound or CT scan. The biliary tract reconstruction by spiral CT scan is as helpful as MRCP or ERCP for clinical diagnosis. For the patients to have the postoperative choledochoscopic helix hydro-jet lithotripsy, they should be diagnosed correctly by T-tube cholangiography and BUS and CT scan. All patients should be verified without stones remaining in the bile duct after lithotripsy by choledochoscopic examination and T-tube cholangiography, and should be examined by BUS again after 6 months to 1 year. We decide whether complications occurred by observation of symptoms and signs after choledochoscopy and lithotripsy.

RESULTS

Seventy-five intrahepatic stones with diameter ranging from 0.6 to 1.5 cm were successfully fragmentized in 30 patients using of helix hydro-jet lithotripsy. These fragmentized stones mainly are bilirubin stones. The lithotripsy was carried for 45 times and the procedure needs 1-1.5 h. Helix hydro-jet lithotripsy are used in 16 cases during operation and 12 cases after operation; two cases during operation and after operation. Intrahepatic calculosis was cleaned out completely and verified by postoperative choledochoscope examination and postoperative T-tube cholangiography examination. No complications were observed.

CONCLUSION

Helix hydro-jet lithotripsy under video choledochoscope is a safe and effective method for the removal of intrahepatic stone. No bile duct damnified and perforation was observed. The procedure is without pain and heat, and the pressure can be adjusted easily. The research provides a new way of using the helix hydro-jet, and a new way of curing the intrahepatic lithiasis.

Gallstone disease: Management of intrahepatic stones

Hepatolithiasis (oriental cholangiohepatitis) has reportedly been endemic only in East Asia. The disease is now occasionally recognized in Western societies, especially in people who have lived in the Orient. Hepatolithiasis is characterized by its intractable nature and frequent recurrence, requiring multiple operative interventions, which is in distinct contrast to gallbladder stones. In addition to frequent cholangitis and chronic sepsis, it is widely known that longstanding intrahepatic stones lead to intrahepatic cholangiocarcinoma. Symptoms of hepatolithiasis include abdominal pain, jaundice and cholangitis. Pyogenic cholangitis due to strictures and hepatolithiasis tends to recur, and sometimes patients may present with liver abscesses. Radiological studies and percutaneous procedures are keys in the diagnosis and treatment of hepatolithiasis. Non-invasive imaging modalities such as ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) accurately depict the normal anatomy and presence of intrahepatic stones. It should be stressed that each modality has its pros and cons, and imaging studies should be performed on the basis of understanding the pathophysiology. As the diagnostic role of magnetic resonance cholangiopancreatography (MRCP) evolves, the roles of both endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC), and their most significant advantage, is primarily therapeutic with their ability to extract stones, biopsy intraductal lesions, and place stents easily. The primary goals of treatment are to eliminate attacks of cholangitis and to stop the progression of the disease (which leads to biliary cirrhosis). Surgery has a primary role in hepatolithiasis because hepatolithiasis tends to recur, so that multiple sessions of the endoscopic approach (i.e. two or three times a year) are often required. PTC is an alternative when surgical resection of the affected lobe is difficult. Techniques for lithotripsy, including shockwave and laser, can be applied in endoscopic sessions, offering a better chance of clearing the stones.

Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones

BACKGROUND

Choledocholithiasis and intrahepatic bile duct stones pose a significant health hazard, especially in the elderly. The large stone not removable with conventional endoscopic techniques, can be effectively and safely managed with electrohydraulic lithotripsy (EHL).

METHODS

This study is a retrospective review of consecutive patients at the Wellesley Central Hospital and St. Michael's Hospital, who underwent peroral endoscopic fragmentation of bile duct stones with EHL under direct cholangioscopic control using a "mother-baby" endoscopic system between October 1990 and March 2002.

RESULTS

To date, 111 patients have been analyzed. Of the 111 patients reviewed, 94 patients have had complete records and were included in this study. Mean follow-up was 26.2 months (range 0-80). Prior to EHL, 93 of 94 patients (99%) had endoscopic retrograde cholangiopancreatography (ERCP) and failed standard stone extraction techniques (mean 1.9 ERCPs/patient, range 0-5). Indications for EHL were large stones (81 patients) or a narrow caliber bile duct below a stone of average size (13 patients). Successful fragmentation (61 complete, 28 partial) was achieved in 89 of 93 patients (96%) (1 patient was excluded from analysis due to a broken endoscope). Fragmentation failures were due to targeting problems (2 patients) and hard stones (2 patients). Seventy-six percent of patients required 1 EHL session, 14% required 2 sessions, and 10% required 3 or more. All patients with successful stone fragmentation required post-EHL balloon or basket extraction of fragments. Complications included: cholangitis and/or jaundice (13 patients); mild hemobilia (1 patient); mild post-ERCP pancreatitis (1 patient); biliary leak (1 patient); and bradycardia (1 patient). There were no deaths related to EHL. Final stone clearance was achieved in 85 of 94 patients (90%).

CONCLUSIONS

EHL via peroral endoscopic choledochoscopy is a highly successful and safe technique for use in the management of difficult choledocholithiasis and intrahepatic stones. This study has shown a stone fragmentation rate of 96% (89 of 93 patients), and a final stone clearance rate of 90% (85 of 94 patients).

Direct cholangioscopy and pancreatoscopy

Direct cholangiopancreatoscopy has played a minor role in the diagnosis and treatment of pancreaticobiliary disorders, initially because of instrument fragility and suboptimal imaging, and later because of improvements in noninvasive and semi-invasive imaging techniques. Digital scopes provide superior images and hold the promise of increased application and improved durability.

Management of difficult common bile duct stones

More than 80% of all CBD stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. For stones up to 2.5 cm in diameter, mechanical lithotripsy is the method of choice as a next step. Very large, impacted, or very hard concretions, however, often make mechanical lithotripsy cumbersome or even impossible. For these stones laser lithotripsy, EHL, and ESWL are nonoperative options, especially for elderly patients and patients with an elevated surgical risk. Because these methods are often only available at endoscopic centers, stenting is a treatment modality for immediate stone therapy, but as a definitive treatment it should be restricted to selected cases. ESWL, EHL, and laser lithotripsy yield similar success rates of 80% to 95% and may be used complementarily in endoscopic centers. ESWL is the preferred therapy in intrahepatic lithiasis. Laser lithotripsy shows the best results in CBD stones. Electrohydraulic lithotripsy is rarely used because of its high potential for tissue damage and bleeding. Laser lithotripsy using smart laser systems such as the rhodamine 6G dye laser and the FREDDY laser system can simplify the treatment of these difficult bile duct stones. The rhodamine 6G-dye laser allows blind fragmentation of these stones by exclusive insertion of a 7-F metal marked standard catheter into the bile duct by standard duodenoscopes using intermittent fluoroscopy. An oSTDS safely cuts off the laser pulse if contact with the stone is lost, thus preserving the bile duct from potential damage. Unfortunately the system is no longer produced. The new FREDDY laser lithotriptor with a piezoacoustic stone/tissue discrimination system offers an alternative to the rhodamine 6G dye laser system at less than half the financial investment. Effective stone fragmentation is accompanied by only low tissue alteration. The holmium:YAG laser is an effective multidisciplinary lithotriptor, but it can be used only under cholangioscopic control, limiting its use to gastroenterologic centers.

Peroral cholangioscopic treatment of hepatolithiasis: Long-term results

BACKGROUND

Peroral cholangioscopic lithotomy is an effective treatment for extrahepatic bile duct stones. However, an evaluation of the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis has not been reported. The aim of this study was to evaluate the usefulness and long-term results of peroral cholangioscopic lithotomy for hepatolithiasis.

METHODS

From August 1987 to July 1998, 36 consecutive patients underwent peroral cholangioscopic lithotomy for hepatolithiasis; 34 were followed for a mean of 93 months (range, 14 to 164 months).

RESULTS

The rate of complete stone removal was 64%; the morbidity rate was 2.8%. The recurrence rate for patients in whom stones were completely removed was 21.7%. Two patients (5.9%) had cholangiocarcinoma develop during follow-up.

CONCLUSION

Although incomplete stone removal and recurrence are common, peroral cholangioscopic lithotomy is a sufficiently safe and effective method for the treatment of hepatolithiasis.

A review of technical and clinical aspects of biliary laser lithotripsy

OBJECTIVE

This paper reviews the current use of laser techniques for the treatment of biliary stones.

BACKGROUND DATA

Biliary stones may pose a special problem when access to them is limited, when previous attempts of removal have failed, or when a less invasive option than surgery is needed. The availability of various laser sources and the adaptation of the technology for safe use in the biliary system make the use of laser energy for stone fragmentation possible.

METHODS

Current literature is reviewed concerning the use of laser for biliary lithotripsy, including experimental data and experience with human series. Technology, indications, alternatives, and cumulative world experience are discussed.

CONCLUSIONS

Recent technical advances have made the use of laser energy for fragmentation of biliary calculi possible. It is a valid option for treatment of "difficult" stones, when other methods have failed or as a primary treatment in certain situations. The technical complexity and the high cost limit its use for specialized centers.