中国胆道结石双频双脉冲激光碎石专家建议

胆道结石是消化系统常见疾病,目前主要治疗手段有外科手术、内镜下介入治疗等,但部分困难结石临床上仍面临挑战。双频双脉冲激光碎石术因其安全、高效等特点,是解决困难结石的有效方法。双频双脉冲掺钕钇铝石榴石激光是目前被国家药品监督管理局批准的可用于胆道结石碎石的激光技术,但其适应证、导入方式和操作规范等问题尚未形成共识。为此,国家消化系统疾病临床医学研究中心(上海)、中国医师协会内镜医师分会和中华医学会消化内镜学分会特邀国内消化、内镜与外科等相关领域专家,在参考国内外文献的基础上,经过充分讨论形成本专家建议,以期为国内规范开展胆道结石激光碎石提供指导和参考。     

《中国胆道结石双频双脉冲激光碎石专家建议》要点解读

双频双脉冲激光碎石术因其安全、高效等特点,为困难胆道结石的治疗提供了新的选择。为进一步规范和合理应用这一技术,由国家消化系统疾病临床医学研究中心(上海)、中国医师协会内镜医师分会和中华医学会消化内镜学分会牵头,制定了《中国胆道结石双频双脉冲激光碎石专家建议》。本文对困难胆道结石的定义、双频双脉冲激光碎石术的优势、导入方...     

胆总管困难结石经内镜激光碎石治疗的有效性和安全性探讨

[目的]探讨经口直接胆道内镜对困难结石激光碎石的有效性和安全性。[方法]对经内镜逆行胰胆管造影(ERCP)并网篮取石或机械碎石篮碎石失败的21例胆总管困难结石患者进行乳头开口小切开联合15 mm大球囊扩张后,插入经口直接胆道内镜至胆总管,沿内镜活检孔插入双频双脉冲(Nd:YAG)激光探头至结石部位直视下激光碎石,研究其插入成功率、并发症发生率、碎石成功率。[结果]21例中17例(80.95%)达到肝门部并发现结石,其中直接插入5例(23.81%),导丝辅助者9例(42.86%),外套管辅助3例(14.29%);失败4例。15例碎石成功(71.43%),其中6例胆道镜清理结石、9例更换十二指肠镜清理。失败4例(19.05%)转外科开腹手术。4例胆道感染,无严重并发症如出血,穿孔,胰腺炎等,也无手术相关死亡。[结论]经口直接胆道内镜介导的困难结石激光碎石是安全有效的,但内镜插入技术有一定困难,需进一步研究。     

输尿管镜下双频双脉冲激光碎石术治疗输尿管结石(附132例报告)

应用双频双脉冲U-100激光经输尿管镜治疗输尿管结石132例,一次治疗成功122例（92．42％）,失败10例（7．58％）,其中上段结石5例,因结石上移至肾盂,留置双J管后行体外冲击波碎石（ESWL）治愈,1例因输尿管狭窄改行开放手术;中下段失败4例,改行开放手术2例,2例放置双J管引流,后行ESWL。认为输尿管镜下双频双脉冲激光碎石术操作简单、安全、有效。     

困难胆总管结石的内镜治疗进展

胆总管结石是一种常见的胆道疾病,首选治疗方式为内镜治疗,但部分胆总管结石难以通过常规内镜治疗清除,被称为困难胆总管结石。困难胆总管结石治疗方法包括内镜下乳头大球囊扩张术、机械碎石术、经口胆道镜辅助碎石和体外冲击波碎石等。就上述技术治疗困难胆总管结石的适应证、临床疗效和不良事件等进展作一综述。     

胆总管结石激光碎石术

胆管结石的内镜去除术已成为一种普遍接受的治疗技术。约90%的胆管结石可经内镜逆行法去除,但很坚硬的结石或嵌顿在胆管内的结石,不能用此法去除,而需要外科手术。内镜逆行激光碎石是一种新方法,它使用普通内镜设备而不需麻醉。病人和操作技术:激光碎石是用闪光灯脉冲钕-钇石榴石(Nd:YAG)激光(波长1064nm)进行操作。激光能量通过一高度弯曲直径0.2mm的石英纤维传送。低能脉冲从结石表面传到结石中心,并不断增大脉冲能量,将结石击碎。本文对9例胆管结石病人应用本法治疗,病人年龄均超过60岁,有些存在着严重的伴发     

激光碎石治疗胆总管结石

经内镜行乳头括约肌切开术和机械性碎石能去除90%患者的胆总管结石,但对坚硬、致密或嵌顿性结石则需手术。其他如水压电碎石、超声碎石及化学溶石亦不满意。作者经内镜逆行激光治疗9例胆总管结石患者。方法:用瑞士脉冲闪光灯Nd:YAG激光(波长1064mm)。先行内境乳头括约肌切开术,2～3日后行激光碎石。9例中6例结石被击碎并从胆管去除。     

经胆道子母镜双频激光治疗巨大难治性胆管结石

我院自2003年10月至2004年7月应用胆道子母镜、双频激光对15例临床治疗困难的巨大胆管结石行碎石治疗,效果满意.     

内镜下乳头括约肌切开并鼻胆管引流对老年巨大肝外胆管结石治疗作用探讨

内镜下鼻胆管引流术(ENBD)是目前常用的胆道引流方法.我们对收治的22例老年巨大肝外胆管结石患者行ENBD,发现留置过程中引流管本身对胆道巨大结石起到的机械性研磨碎石作用,国内相关报道较少,现总结如下.     

内镜下激光碎石术治疗胆总管难治性结石护理配合体会

以ERCP为基础的内镜下取石是治疗胆总管结石的首选方法,但直径〉1．5cm的巨大结石和嵌顿性结石,经ERCP网篮取石难度明显增大,这类胆总管结石被称为胆总管难治性结石。我院消化内镜中心自2009年8月采用WOM公司（德国）生产的双频激光碎石机对于该类难治性胆总管结石进行内镜下治疗,取得一定效果,现将治疗护理配合体会总结如下。     

How Should Biliary Stones be Managed?

Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures.     

Laser lithotripsy of difficult bile duct stones under direct visual control.

Biliary laser lithotripsy was performed under direct visual control in 35 consecutive patients not amenable to routine endoscopy. The patients had 1-50 (median 1) bile duct stones with the greatest diameter of the largest stone being 9-42 mm (median 20 mm). Conventional endoscopic treatment had failed because of an inaccessible papilla (16 patients), biliary strictures (seven patients), and impaction or large size of calculi (12 patients). Twelve patients, depending on their anatomical condition, underwent peroral cholangioscopy by means of a mother-babyscope system. Percutaneous cholangioscopy was initially carried out in 23 patients, 7-20 days (median 10 days) after creation of a transhepatic fistula. Pulsed dye laser (32 patients) or alexandrite laser (three patients) lithotripsy was applied under an appropriate direct visual control in all cases. Complete stone disintegration succeeded in 33 of 35 patients. All resultant fragments passed the papilla within a mean number of 1.3 treatment sessions. Peroral cholangioscopic lithotripsy failed in two cases. One patient successfully underwent percutaneous laser treatment and the other patient was referred to surgery. Fever, temporary haemobilia, or a subcapsular liver haematoma were seen in a total of eight patients during establishment of the cutaneobiliary fistula. A 95 year old patient who had been admitted with septic cholangitis died because of cardiorespiratory failure 5 days after bile duct clearance. It is concluded that laser lithotripsy performed under a direct visual control is an effective and safe procedure for the non-surgical treatment of difficult bile duct stones. Ductal clearance can usually be achieved in a single treatment session when the papilla and the stones are accessible by the peroral route. Percutaneous cholangioscopic lithotripsy is more time consuming but highly effective even in patients with a difficult anatomy, bile duct strictures, or intrahepatic calculi. This approach should be limited, however, to cases not amenable to retrograde procedures because the creation of the cutaneobiliary fistula is not without risks.     

Clinical usefulness of transpapillary removal of common bile duct stones by frequency doubled double pulse Nd：YAG laser

AIM： To study the efficacy and the safety of laser lithotripsy without direct visual control by using a balloon catheter in patients with bile duct stones that could not be extracted by standard technique.
METHODS： The seventeen patients （7 male and 10 female; mean age 67.8 years） with difficult common bile duct （CBD） stones were not amenable for conventional endoscopic maneuvers such as sphincterotomy and mechanical lithotripsy were included in this study. Laser wavelengths of 532 nm and 1064 nm as a double pulse were applied with pulse energy of 120 mJ. The laser fiber was advanced under fluoroscopic control through the ERCP balloon catheter. Laser lithotripsy was continued until the fragment size seemed to be less than 10 mm. Endoscopic extraction of the stones and fragments was performed with the use of the Dormia basket and balloon catheter.
RESULTS： Bile duct clearance was achieved in 15 of 17 patients （88%）. The mean number of treatment sessions was 1.7 ± 0.6. Endoscopic stone removal could not be achieved in 2 patients （7%）. Adverse effects were noted in three patients （hemobilia, pancreatitis, and cholangitis）.
CONCLUSION： The Frequency Doubled Double Pulse Nd：YAG （FREDDY） laser may be an effective and safe technique in treatment of difficult bile duct stones.     

Intracorporeal Shock Wave Lithotripsy (ISWL) in Bile Ducts under Peroral Endoscopy: Progress and Current Status

Attempting to use ISWL (intracorporeal shock wave lithotripsy) for treating large and difficult biliary stones was started in the mid 1970s, approximately 10 years before the introduction of ESWL (extracorporeal shock wave lithotripsy). However, in contrast to ESWL, ISWL did not quickly become popular in practise. The main reason for this delayed recognition, undoubtedly, lay in the technical difficulties of the peroral applications until the mid 1980s, when the development of an improved cholangios-cope system and a thin, flexible probe allowed the use of EHL (electrohydraulic lithotripsy) under direct vision during peroral cholangioscopy. Thanks to recent advances in technology, a powerful pulsed laser has begun to be used for ISWL through a 0.2 mm sized quartz fiber. A laser version of ISWL with such a thin probe is expected to facilitate its use by minimizing the endoscope system. The automatic stone-tissue recognition system which interrupts the laser discharge in case of wall contact is another useful advance in technology which increases the safety and therapeutic efficacy. Whereas laser techniques are still in development, ISWL with a laser will be the first choice technique for treating difficult bile duct stones after failure of mechanical lithotripsy and it also promises to improve its therapeutic efficacy for intrahepatic stones in combination with ESWL. In this article, the recent progresses and results of ISWL treatment were reviewed with a respect to the success of ESWL.     

Endoscopic management of bile duct stones

The advantages of endoscopic retrograde cholangiopancreatography (ERCP) over open surgery make it the predominant method of treating choledocholithiasis. Today, technologic advances such as magnetic resonance cholangiopancreatography and laparoscopic surgery are challenging ERCP's primacy in the management of common bile duct (CBD) stones. This article reviews the current status of endoscopic treatment of biliary stones and examines this in relation to laparoscopic management. The techniques and safety of endoscopic sphincterotomy and balloon sphincteroplasty are reviewed. Balloon sphincteroplasty should be limited to study protocols because of safety questions and inherent limitations. After sphincterotomy, 85% to 90% of CBD stones can be removed with a Dormia basket or balloon catheter. These techniques are described as having both advantages and disadvantages. Methods for managing "difficult stones" include mechanical lithotripsy, intraductal shock wave lithotripsy, extracorporeal shock wave lithotripsy, chemical dissolution, and biliary stenting. These approaches are presented along with data supporting their use in specific situations. Laparoscopic cholecystectomy has emerged as the preferred alternative to open cholecystectomy. Parallel advances in the endoscopic and laparoscopic management of CBD stones have made the issue regarding the optimal treatment strategy complex. Three approaches to the management of choledocholithiasis in the laparoscopic era are presented as follows: strict therapeutic splitting, flexible therapeutic splitting, and strict laparoscopic management. The optimal approach needs to be defined in prospective comparative trials. For now, preoperative endoscopic stone extraction should still be recommended as the approach of choice in patients suspected to have CBD stones based on clinical, biochemical, and imaging parameters. Primary laparoscopic evaluation and management is reasonable in patients who have a low-to-moderate probability of having CBD stones.     

Recent advances in endoscopic management of difficult bile duct stones

Endoscopic treatment is now recognized worldwide as the first‐line treatment for bile duct stones. Endoscopic sphincterotomy combined with basket and/or balloon catheter is generally carried out for stone extraction. However, some stones are refractory to treatment under certain circumstances, necessitating additional/other therapeutic modalities. Large bile duct stones are typically treated by mechanical lithotripsy. However, if this fails, laser or electrohydraulic lithotripsy (EHL) is carried out under the guidance of conventional mother‐baby cholangioscopy. More recently, direct cholangioscopy using an ultrathin gastroscope and the newly developed single‐use cholangioscope system – the SpyGlass direct visualization system – are also used. In addition, extracorporeal shock wave lithotripsy has also been used for stone fragmentation. Such fragmentation techniques are effective in cases with impacted stones, including Mirizzi syndrome. Most recently, endoscopic papillary large balloon dilationhas been introduced as an easy and effective technique for treating large and multiple stones. In cases of altered anatomy, it is often difficult to reach the papilla; in such cases, a percutaneous transhepatic approach, such as EHL or laser lithotripsy under percutaneous transhepatic cholangioscopy, can be a treatment option. Moreover, enteroscopy has recently been used to reach the papilla. Furthermore, an endoscopic ultrasound‐guided procedure has been attempted most recently. In elderly patients and those with very poor general condition, biliary stenting only is sometimes carried out with or without giving subsequent dissolution agents.     

X线监视下激光碎石治疗难治性胆总管结石的效果研究

目的 探讨X线监视下激光碎石治疗难治性胆总管结石的效果和安全性.方法 将40例难治性胆总管结石患者分为两组,分别在子镜监视下（子镜监视组,21例）及X线监视下（X线监视组,19例）进行激光碎石治疗,比较两组间结石取净率、并发症发生率.结果 子镜监视组共取净结石19例（90.5%）,X线监视组取净17例（89.5%）,两组间结石取净率差异无统计学意义（P=0.658） 两组间并发症发生率差异无统计学意义（19.0%比15.8% P=0.559）.结论 治疗难治性胆总管结石X线监视与子镜监视两种方法是同样安全有效.     

Oldest biliary endoprosthesis in situ

The advantages of endoscopic retrograde cholangiopancreatography over open surgery have made it the predominant method of treating patients with choledocholithiasis. After sphincterotomy, however, 10%-15% of common bile duct stones cannot be removed with a basket or balloon. The methods for managing “irretrievable stones” include surgery, mechanical lithotripsy, intraductal or extracorporeal shock wave lithotripsy and biliary stenting. The case presented was a referred 82-year-old Caucasian woman with a 7-year-old plastic biliary endoprosthesis in situ. To the best of our knowledge the examined endoprosthesis is the oldest endoprosthesis in situ reported in the literature. Endoscopic biliary endoprosthesis placement remains a simple and safe procedure for patients with stones that are difficult to manage by conventional endoscopic methods and for patients who are unfit for surgery or who are high surgical risks. To date no consensus has been reached regarding how long a biliary prosthesis should remain in situ. Long-term biliary stenting may have a role in selected elderly patients if stones extraction has failed because the procedure may prevent stones impaction and cholangitis.     

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD) stone is a common biliary problem, which often requires endoscopic approach as the initial treatment option. Roughly, 7%-12% of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management. In general, there are three classifications of difficult CBD stone, which are based on the characteristics of the stone(larger than 15 mm, barrel or square-shaped stones, and hard consistency), accessibility to papilla related to anatomical variations, and other clinical conditions or comorbidities of the patients. Currently, endoscopic papillary large balloon dilation(EPLBD) of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts. If failed extraction is still encountered, mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered. Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available. To our knowledge, conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches. The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.     

ENDOSCOPIC REMOVAL OF AN ENTEROLITH CAUSING AFFERENT LOOP SYNDROME USING ELECTROHYDRAULIC LITHOTRIPSY

Electrohydraulic lithotripsy is a very useful method for fragmenting biliary stones and it can be used for endoscopic removal of difficult biliary stones. Acute afferent loop syndrome induced by enterolith is very rare, and surgical treatment is the usual choice for this condition. We describe a patient with acute afferent loop syndrome, which was induced by an enterolith after a Billroth II gastrectomy. We used electrohydraulic lithotripsy to endoscopically remove the enterolith.