The value of extracorporeal shock-wave lithotripsy in the management of bile duct stones

We evaluated the role of biliary extracorporeal shock-wave lithotripsy in treating 70 symptomatic patients with bile duct stones in whom endoscopic or percutaneous radiologic attempts at basket extraction had failed. Forty-four patients had common bile and/or common hepatic duct stones, 21 patients had cystic duct stones, and five patients had intrahepatic duct stones. A total of 43 patients (61%) had complete elimination of stone fragments during the initial treatment period. If patients in whom stones were successfully fragmented yet not totally eliminated on initial hospital treatment but who were asymptomatic at follow-up times of 8-22 months are included, the overall successful treatment rate was 83%. Stones were cleared in 26 of 44 common bile/hepatic duct stone patients, spontaneously in seven patients and after endoscopic or percutaneous radiologic intervention in 19 patients. Fifteen (71%) of 21 patients had cystic duct stones successfully cleared. The fragments in two of five patients with intrahepatic duct stones also were cleared. Five patients (7%) had minor side effects. Seven (10%) of 70 patients went on to have surgery. Complications after 30 days occurred in five patients (7%); two required repeated endoscopy with fragment extraction, two required placement of an endoprosthesis, and one died. We conclude that biliary extracorporeal shock-wave lithotripsy is valuable as an adjuvant to standard interventional techniques for removing bile duct stones.     

Transcutaneous chemical cholelitholysis with methyl tert-butyl ether (MTBE). lst results in man

Three patients have been treated, with instillation of MTBE through a transcutaneous biliary drainage after transduodenal sphincterotomy. The first had gallbladder stones, the second common bile duct stones and the last intrahepatic stones (V segment). While in the first case there has been only a partial success in the other two we have obtained a total dissolution of the stones, with complete clinical recovery. This treatment has not caused immediate side effects but the absence of long term damage has not yet been proven. We think that the use of MTBE is not indicated in gallbladder stone disease. Its major indication is the dissolution of ductal gallstones when transduodenal sphincterotomy and endoscopic removal of the stones have failed.     

Common bile duct calculi: updated experience with dissolution with methyl tertiary butyl ether

The authors describe their experience with methyl tertiary butyl ether (MTBE) in a larger series of patients than previously reported in order to acquaint physicians with both its effectiveness for dissolution of common bile duct calculi and the limitations of its use. Ten patients with 13 biliary calculi underwent percutaneous stone dissolution treatment with the experimental cholesterol solvent, MTBE. Three stones completely dissolved within 30 minutes, seven were reduced in size, and three were visibly unaffected. All stones not completely dissolved were easily extracted by means of a stone basket except for one in a patient taken to surgery. Although MTBE perfusion is an effective technique for management of biliary calculi, practitioners should be aware that its use is quite time consuming and its odor difficult to control.     

Percutaneous contact dissolution of gallstones: complexity of radiologic care

The clinical and technical considerations for successful gallstone dissolution with methyl tert-butyl ether (MTBE) are often underestimated. Patients are selected for MTBE therapy on the basis of a functioning gallbladder without evidence of acute inflammation or calcified stones at plain radiography. A transhepatic route is favored for percutaneous insertion of the cholecystostomy catheter because of the theoretic reduced frequency of bile leakage. MTBE is delivered manually through the catheter in a closed system, with dissolution times of 4-16 hours. After MTBE dissolution, residual debris in the gallbladder is present at follow-up sonography in up to 75% of patients. The high frequency of residual debris, the potential for stone recurrence, and the labor-intensive nature of MTBE therapy make its future uncertain, especially with the advent of laparoscopic cholecystectomy.     

Treatment of bile duct stones by laser lithotripsy: results in 12 patients.

We used a pulsed tunable dye laser (operating at 60 mJ per pulse, 504-nm wavelength) to fragment large (0.8-4.5 cm) stones retained in the hepatic ducts or common bile duct in 12 patients after cholecystectomy. Attempts to extract stones via a T-tube or endoscope had been unsuccessful in all patients. In nine of 12 patients, all stone fragments were successfully eliminated during the initial treatment. In one patient, fragmentation occurred but debris remained, requiring endoscopic stenting. Pseudomonas sepsis developed in this patient 30 days after the procedure and was treated by extraction of the stone fragments. Fragments remaining after lithotripsy were cleared at the same sitting by using saline flushing or endoscopic or percutaneous basket extraction. In two of 12 patients, the treatment was unsuccessful because of laser malfunction. The treatment was performed without complications, except for clinically insignificant hyperamylasemia, which occurred in two patients. Our experience suggests that laser lithotripsy offers a safe alternative for nonsurgical treatment of large retained biliary stones for patients in whom traditional treatments have failed.     

经皮经肝取石术治疗胆总管结石25例

目的 探讨经皮经肝胆结石取出术治疗胆总管结石的临床应用价值.方法 自2013年1月至2015年1月,25例胆总管结石患者采用经皮经肝途径取石.首先在超声或者X线透视引导下完成PTC并放置8F鞘;然后采用8～12 mm球囊扩张乳头,如结石直径超12 mm,加用网篮碎石;最后采用取石球囊通过交换导丝将结石经十二指肠乳头括约肌推至肠道内.结果 25例患者包括胃肠道术后(18例)、内镜治疗失败(3例)、不愿意接受内镜治疗(3例)、其他情况(1例).25例患者均成功取出结石.术后3例(12％)发生并发症,分别为发热2例、肝脓肿形成1例,随访6个月到3年,2例患者因原患肿瘤复发转移死亡,1例患者胆总管结石复发,无反流性胆管炎发生.结论 经皮经肝胆结石取出术治疗胆总管结石具有较高的手术成功率以及较低的并发症发生率,可以作为不适合内镜治疗或者内镜治疗失败的胆总管结石患者的治疗措施.     

Combined surgical and radiologic intervention for complicated cholelithiasis in high-risk patients

Ultrasound-guided surgical cholecystostomy with local infiltration anesthesia was combined with radiologic removal of gallstones in 36 elderly patients with acute calculous gallbladder disease who were considered to be at high risk due to multiple coexisting diseases. At cholecystostomy, the fundus of the gallbladder was sutured to the anterior abdominal wall resulting in a short surgical track to the gallbladder. This permitted early percutaneous stone removal through the cholecystostomy track under fluoroscopic guidance. All gallstones were removed in 31 of 36 patients, for an overall success rate of 86%. The success rate was 97% for gallbladder stones, 86% for cystic duct stones, and 63% for common bile duct stones that were removed by traversing the cystic duct. The treatment in the five patients in whom radiologic stone removal was incomplete or unsuccessful consisted of elective cholecystectomy in three, with common bile duct exploration in two of these; endoscopic sphincterotomy and stone extraction in one; and expectant management in one. There were no deaths or serious complications. This technique has thus proved safe and effective in these 36 high-risk patients.     

嵌顿性胆总管或胆囊管结石的介入性综合治疗

目的 评价多种介入性取石技术综合应用于１组患有嵌顿性胆管结石,且被视为手术高危病人的治疗效果。方法 ９例（男２例,女７例,平均年龄５０．７岁）患者中,６例曾有接受内窥镜下取石失败或手术直视下取石再复发的病史;在发生部位上,计有７例胆总管结石,１例胆囊管结石,１例胆总管合并胆囊管残端结石;多发性结石５例,单发性结石４例;最大结石直径约为３．０ｃｍ。在处理方法上,建立经皮肝胆管和内窥镜下经十二指肠逆向     

Iodinated contrast medium as an aid to gallstone dissolution with methyl tert-butyl ether: in vitro study

Methyl tert-butyl ether (MTBE) floats on bile, whereas gallstones sink. Therefore, stones and MTBE are separated by a layer of bile. This study investigates the effect of contrast medium on flotation of gallstones in bile and its role in stone and fragment dissolution with MTBE. Fresh human gallstones, both calcified and noncalcified, from different patients were tested in vitro for flotation in bile, with and without addition of contrast medium. All gallstones or fragments sank in bile before the introduction of contrast medium. Noncalcified stones floated when the contrast medium-bile volume ratio was 1:6 or more, while double this amount of contrast medium was required to float calcified stones. Fragments did dissolve somewhat in MTBE in the presence of bile alone, but when contrast medium was added, almost complete dissolution occurred. This is thought to be due to increased contact between the fragments and MTBE, both floating on the contrast medium-bile mixture. Contrast material may be a useful adjuvant in gallstone dissolution therapy with MTBE in vivo.     

Percutaneous Cholangioscopy in the Management of Biliary Disease: Experience in 25 Patients

Purpose: To present our experience performing percutaneous cholangioscopy in the management of 25 patients with biliary disease. Methods: During the last 3 years, 26 percutaneous cholangioscopies were performed in 25 patients with common bile duct disease (n = 16), intrahepatic ducts disease (n = 6), and gallbladder disease (n = 4). Our patient population group included seven with common bile duct stones, three with intrahepatic lithiasis, and eight with benign strictures (six iatrogenic and two postinflammatory). In four patients malignancy was to be excluded, in two the tumor extent was to be evaluated, whereas in one case the correct placement of a metallic stent needed to be controlled. A 9.9 Fr flexible endoscope URF-P (Olympus, 1.2 mm working channel, 70-cm length) was used. Results: In total, percutaneous cholangioscopy answered 30 diagnostic questions, was technically helpful in 19 cases (performing lithotripsy or biopsy or guiding a wire), and of therapeutic help in 12 (performing stone retrieval). In 24 of 26 cases the therapeutic decision and the patient management changed because of the findings or because of the help of the method. In two cases biliary intervention failed to treat the cause of the disease. No major complication due to the use of the endoscopy was noted. Conclusions: Percutaneous cholangioscopy is a very useful tool in the management of patients with biliary disease. The method can help in diagnosis, in performing complex interventional procedures, and in making or changing therapeutic decisions.     

Extracorporeal shock-wave lithotripsy in the management of bile duct stones

Extracorporeal shock-wave lithotripsy (ESWL) was performed in 16 patients with bile duct stones. Dornier HM3 water-bath equipment (Dornier Medical Systems, Marietta, GA) was used in all procedures. All patients had either a T-tube or a nasobiliary, cholecystostomy, or transhepatic biliary drainage tube in place at the time of the lithotripsy. In 12 patients, the indication for ESWL was the failure of or anticipated difficulty with basket extraction of the stones, either via a T-tube tract or by means of endoscopic sphincterotomy. In the other four patients, ESWL was performed immediately after retained stones were found on a postoperative cholangiogram, even though no difficulty was anticipated in removing the stones by means of basket extraction. In 15 (94%) of the 16 patients, the stones were successfully fragmented. The fragments passed spontaneously in nine patients but had to be removed by basket in five patients. In one patient, the fragments could not be extracted by basket. The number of ESWL shocks used in a single session ranged from 525 to 3200. Three patients had two ESWL sessions. No significant complications were observed. ESWL is a successful method for the management of patients with bile duct stones when used in conjunction with other nonsurgical techniques. It was also the only treatment required in 56% of our patients.     

Percutaneous transhepatic holmium laser lithotripsy for cholelithiasis and balloon dilation for common bile duct stone removal

Biliary lithiasis is common in clinical practice. We present the case of a 53-year-old man referred to our hospital with a history of biliary lithiasis. Abdominal magnetic resonance imaging revealed gallbladder stones and common bile duct stones. To avoid surgery, we opted to apply percutaneous transhepatic techniques to clear gallbladder and bile duct stones. This study reports our experience using these techniques, including percutaneous transhepatic holmium laser lithotripsy for cholelithiasis combined with balloon dilation to remove common bile duct stones and avoid open surgery.     

Common Bile Duct Stones Detected After Cholecystectomy: Advancement into the Duodenum via the Percutaneous Route

Purpose: To report our experience in the use of percutaneous extraction of common bile duct stones detected in the post-cholecystectomy period. Methods: Forty-two patients in whom endoscopic cannulation and/or sphincterotomy had failed or could not be done due to several reasons underwent balloon dilatation of the ampulla of Vater and subsequent advancement of the stones via the percutaneous transhepatic route or T-tube tract. Results: The procedure was successful in 42 cases. In three patients, stones were crushed in the common bile duct and pushed as fragments into the duodenum. In all cases transient adverse effects were observed. There were no major complications. All cases were checked with ultrasonography for 6 months after the procedure. Conclusion: Percutaneous extraction of common bile duct stones is an effective method of treatment with a high success rate, low complication rate and shorter hospital stay. It may serve as an alternative method in cases where endoscopic removal of stones fails.     

Interventional radiology of the biliary tract. Transcholecystic intervention

Diagnostic and therapeutic biliary intervention by percutaneous access to the gallbladder is an important new area in interventional radiology. The anatomy of the gallbladder, biliary tree, and surrounding viscera is reviewed in this article as a preliminary to discussion of the diagnostic techniques of aspiration, cholangiography, biopsy, and the therapeutic techniques of gallbladder drainage and cholelithotomy. Recently there has been a bewildering proliferation of procedures aimed at removal, fragmentation, and dissolution of gallbladder stones. Several of these are discussed in this article. Removal of common bile duct stones by percutaneous cholecystostomy also is discussed.     

Tissue response of the biliary and digestive system of rabbits after MTBE infusion into the gallbladder

We evaluated the tissue response of the biliary and digestive system after Methyl-tert-Butyl-Ether (MTBE) gallbladder infusion in 32 rabbits. After laparotomy, MTBE (5-11 ml) was infused into the gallbladder for eight hours. Animals were sacrificed after eight hours or after two months. Control animals received saline solution infusion into the gallbladder. Afterwards the gallbladder, the common bile duct, the liver, the pancreas and the duodenum were examined histologically. All animals receiving MTBE had different degrees of gallbladder necrosis, common bile duct necrosis and necrosis of intrahepatic bile ducts. After two months, scar formation and a hyperplastic cholecystitis were observed. Control animals did not have comparable tissue reactions; only small areas of necrosis in the gallbladder and the common bile duct occurred after eight hours. The gallbladder, common bile duct and liver remained unchanged in those animals which survived two months. Although the results of this animal study cannot be directly transferred to humans, the data suggest that MTBE should be used in gallstone therapy with caution, and that if it is used, a well-controlled follow-up of these patients is necessary.     

The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.

AIM: To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and ultrasound (US) in the diagnosis of choledocholithiasis in a large group of patients with bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stone characteristics using the three different investigations, endoscopic retrograde cholangiopancreatography (ERCP), MRCP and US. MATERIALS AND METHODS: 191 patients (M:F, 76:115; mean age, 66 years; range, 24-92 years) were investigated by direct cholangiography, MRCP and US. Their final diagnosis as determined at direct cholangiography were choledocholithiasis (n = 34), strictures (n = 47) and normal ducts (n = 110). The direct cholangiographic methods used for diagnosis of choledocholithiasis were ERCP (n = 29), intraoperative cholangiography (n = 3) and percutaneous transhepatic cholangiography (n = 2). The bile duct stone characteristics were compared using ERCP, MRCP and US in the 29 patients in whom stones were exclusively diagnosed by ERCP. RESULTS: Compared with the final diagnosis, MRCP had a sensitivity, specificity and diagnostic accuracy of 91%, 98% and 97%, respectively, in the diagnosis of choledocholithiasis. MRCP resulted in three false-negative and three false-positive findings, four of which occurred due to confusion with lesions at the ampulla. US had a sensitivity, specificity and diagnostic accuracy of 38%, 100% and 89%, respectively, in the diagnosis of choledocholithiasis. ERCP diagnosed more stones and the stones were more proximally distributed within the bile duct at ERCP when compared with MRCP. CONCLUSION: MRCP has a high diagnostic accuracy (97%), similar to that at direct cholangiography, in the diagnosis of choloedocholithiasis. It has the potential to replace diagnostic ERCP and select patients with choledocholithiasis for therapeutic ERCP.     

Gallstone lithotripsy: in vitro comparison of fragmentation with a tunable-dye laser and an ultrasonic wire.

Large bile duct stones require fragmentation prior to extraction through the papilla or through a percutaneous tract. This can be attempted with dissolution therapy, crushing baskets, or lithotripsy. Lithotripsy can be accomplished safely and effectively with tunable-dye laser energy delivered through a flexible, 1-F optical fiber under endoscopic or fluoroscopic guidance, but laser technology is very costly. A prototype, flexible ball-tipped wire coupled to an ultrasonic generator via a piezoelectric crystal has been developed for sonolysis of atheroma and thrombus in humans. The purpose of this experiment was to compare human gallstone fragmentation in vitro with a tunable-dye laser and this prototype wire to see if the less expensive ultrasound device might provide an alternative to costly laser technology. Gallstones from 17 patients were subjected to lithotripsy in a water bath with each device until completely fragmented or 60 seconds had elapsed. Neither device effectively fragmented cholesterol stones under these conditions. The ultrasonic wire completely fragmented 57% of bilirubinate stones in 60 seconds. The tunable-dye laser completely fragmented 100% of bilirubinate stones in less than 35 seconds (P = .04). Tunable-dye laser lithotripsy appears superior to the ultrasonic device for percutaneous treatment of bile duct stones.     

Dissolution of multiple biliary duct stones using methyl tert-butyl ether (MTBE): Experience in two cases

Methyl tert-butyl-ether (MTBE) was sucessfully used for stone dissolution in 2 patients with multiple bile duct cholesterol stones. The presence of a biliary-enteric anastomosis precluded the endoccopic approach. Because of leakage of MTBE into the bowel, dissolution time ranged from 7.5 to 36 h. No significant complications other than mild nausea were encountered. No recurrence of stone formation has been found at a follow-up varying from 9 to 12 months.     

Biliary malignancies occurring in choledochal cysts

Eight cases of choledochal cyst associated with biliary malignancy (gallbladder carcinoma in three and bile duct carcinoma in five) were reviewed to evaluate the roles and limitations of computed tomography (CT) (n = 8), ultrasound (US) (n = 6), cholangiography (n = 8), and angiography (n = 6). In cases of gallbladder carcinoma, both CT and US revealed mass lesions in the gallbladder consistent with cancer. CT also depicted either a mass lesion or an irregular thickened wall in all cases of bile duct carcinoma; however, US failed to demonstrate a thickened wall in one of three cases in which CT findings were positive. Cholangiography universally revealed malunion of the pancreatico-biliary duct, and the findings were suggestive of malignancy in seven cases in which CT depicted abnormalities. Angiography showed tumor stain in three of six cases. Lymph node metastases were present in four cases but were detected preoperatively in only one. One case showing a thickened bile duct wall was erroneously diagnosed as malignancy among 27 cases of choledochal cyst unassociated with biliary malignancy.     

Comparison of percutaneous and endoscopic retrograde removal of postoperatively retained bile duct stones

Forty-one patients underwent nonsurgical removal of postoperatively retained bile duct stones in two nonrandomized groups. The endoscopic-retrograde technique was used in 21 patients, and succeeded in 19. The percutaneous approach through the T-tube tract was used in 22 patients, including the two in whom endoscopic stone removal had failed, and was successful in 21 patients. Individual preferences and prior history introduced a selection bias against the percutaneous technique. Auxiliary extracorporeal shockwave lithotripsy (ESWL) was used in 2 patients whose stones could not be fragmented mechanically by the percutaneous basket technique. ESWL was successful in one patient but failed in the second. Because endoscopy had also failed in this case, the patient subsequently underwent repeat surgery. Procedure-related complications were minor with both techniques and were readily treated by conservative measures. We conclude that both the retrograde and the percutaneous approaches are effective and safe. The endoscopic approach appears convenient because there is no need to await maturation of the percutaneous tract, but sphincterotomy carries a small but distinctive risk. Because the percutaneous approach uses an existing tract, is only minimally invasive and leaves the sphincter of Oddi intact, it is preferable in those patients who have T-tubes of approapriate size and position in place.