Electrohydraulic lithotripsy of intrahepatic stones during choledochoscopy

In two patients, electrohydraulic lithotripsy was used under direct vision during choledochoscopy to fragment intrahepatic calculi above bile duct strictures, which were difficult to remove by ordinary choledochoscopic methods. Choledochoscopy was performed after dilation of a percutaneous transhepatic tract in one patient and after intubation of the subcutaneous blind jejunal limb of a previous Roux-en-Y intrahepatic cholangiojejunostomy in the other. Both patients were treated without any complications. Electrohydraulic lithotripsy during choledochoscopy is a safe and effective method to fragment stones and facilitate their removal.     

Complications of nonoperative extraction of retained common duct stones.

A morbidity of 5 per cent and no mortality occurred in 612 reported patients undergoing nonoperative extraction of retained common duct stones. Three patients with complications required reoperation, but morbidity and mortality with this new procedure of percutaneous stone removal is significantcantly less than that with operative reexploration of the common duct. The use of small caliber T tubes results in a greater rate of failure and entails more complications. A T tube of no less than number 14 French caliber should be used routinely [2]. Penrose drains should be placed separately from the T tube, and the T tube should be brought out through a lateral stab wound.     

Subcutaneous implantation of KMC tube for removal of recurrent intrahepatic stones without laparotomy

About half of 361 patients with intrahepatic stones had recurrent stone(s) requiring additional surgery in the past 10 years. In order to cope with this problem, a new tube referred to as the KMC (Kaohsiung Medical College) tube was developed to allow the removal of stones without additional surgery. This tube was implanted subcutaneously between the common bile duct and the abdominal wall after successful extrication of intra- or extra-hepatic stones. Thirty-nine patients with intrahepatic stones were accepted for this new trial. The surgical procedure consisted of first removing the biliary drainage tube followed by insertion of the KMC tube. The KMC tube was introduced through a small skin incision under local anesthesia and the KMC tube fixed with abdominal fascia. The benefit of this procedure is that the contrast medium could be percutaneously injected into the tube for follow-up cholangiographic study when necessary. The procedure for removal of recurrent stones included removing the KMC tube under local anesthesia, then inserting the choledochofiberscope through the original sinus tract to engage the stone(s) without laparotomy. This procedure had been performed on 4 patients with successful removal of their recurrent stones after 6 to 24 months without the necessity for abdominal surgery.     

经胆道输尿管镜体压弹道碎石处理肝内胆管结石

回顾性分析16例复杂肝内胆管结石患者术中应用经胆道输尿管镜体压弹道碎石术的临床资料。其中15例患者结石取净,1例术后经T管胆道造影及复查B超提示胆总管下段有泥沙样结石残留,经胆道冲洗后结石消失。提示:应用电视监视下经胆道输尿管镜体压弹道碎石是处理复杂肝内胆管结石的一种有效方法,可明显提高肝内胆管结石的疗效,减少结石残留。     

Retained common bile duct stones. Endoscopic papillotomy is the preferred approach

In six patients who had undergone cholecystectomy and common bile duct exploration, the postoperative T-tube cholangiogram demonstrated stones. Endoscopic cholangiography demonstrated a normal common bile duct in 2 patients and stones in 4 patients. In the latter group, endoscopic papillotomy and stone extraction were successful.     

Choledochofiberoscopy in the postoperative management of intrahepatic stones

We prefer a nonaggressive approach to the treatment of high risk patients with intrahepatic stones. We perform extensive choledochotomy, remove all accessible intrahepatic stones, use bouginage of all stenotic segments and maintain patency with a T-tube stent. Postoperatively, we extract the remaining intrahepatic stones mainly with the choledochofiberscope and various types of forceps. The combined use of the Burhenne catheter and Dormia basket and the different types of curved forceps, scoops and Bakes' dilator has improved the success rate of removal. Thirty patients have thus far been treated in this manner with encouraging results.     

The nonoperative removal of retained common duct stones after biliary surgery with clofibrate.

We present the first clinical case of multiple residual choledocholithiasis successfully treated with trans-T-tube clofibrate perfusions, to appear in the world's medical literature. Perfusions were carried out with a solution consisting of: 1500 mg of clofibrate, 4 mg of dexamethasone, in 250 ml of isotonic saline solution; the first previously dissolved in 10 ml of ethyl alcohol. The perfusions were consistently carried out at 8-h intervals. After 1 week, a follow-up cholangiogram showed only stone remaining in the terminal portion of the common bile duct. Clofibrate irrigations were continued and 5 days later a new cholangiogram showed and absolutely permeable biliary tract through which the contrast passed freely into the duodenum. This case clinically confirms our previous in vitro studies, which demonstrated the extraordinary litholitic capacity of clofibrate.     

Extracorporeal lithotripsy. An important adjunct in the nonoperative management of retained or recurrent bile duct stones.

Retained or recurrent bile duct stones can be successfully removed in up to 80% to 85% of patients with the use of percutaneous or endoscopic techniques. However, problems related to difficult biliary access, large stones, and biliary strictures may decrease the success rate of this approach. We evaluated the safety and efficacy of extracorporeal shock-wave lithotripsy (ESWL) in 16 patients with complicated biliary stones treated prospectively over a 24-month period. Successful stone fragmentation was achieved in 15 patients (94%) using a Dornier HM3 lithotripter (average of 2290 shocks at 22 kV). Three patients (19%) required a second ESWL treatment. Biliary clearance of stone fragments was spontaneous in seven (43%) of the patients and required additional treatment in eight (57%) of the patients. Complications from ESWL were minor and included transient hematuria and ecchymoses at the skin entry site. Extracorporeal shock-wave lithotripsy failed in one patient (6%) with a biliary stricture and surgery was required. At hospital discharge, all patients were asymptomatic and stone free. Treatment with ESWL appears to be a safe and effective adjunct for selected patients with complex biliary stone disease.     

Use of stone brush for treatment of impacted stones in association with extracorporeal shock-wave lithotripsy

A new device is described which enhances the treatment of impacted stones in association with the extracorporeal shock-wave lithotripsy. This technique may result in decreased number of shocks and increased efficiency, as well as, enhance outpatient treatment.     

肝叶切除治疗肝胆管结石

原发性肝内胆管结石主要是以胆色素为主的泥砂样结石。由于其病理变化十分复杂,手术常无定式,故处理起来比胆固醇结石要困难得多。许多病人往往经过多次手术仍不能彻底解除病痛。肝胆管结石的确定性治疗原则首先是先去除肝内结石,然后处理胆管狭窄（后者是造成肝内胆管...     

How can cholangioscopy improve the management of intrahepatic stones?

Summary Experience with endoscopic treatment of intrahepatic stones in 93 cases encountered over 13 years starting in 1974 was analyzed and the usefulness of the procedure is discussed in this paper. Postoperative cholangioscopy are percutaneous transhepatic cholangioscopy are easy, safe and reliable procedures because they can be carried out under both fluoroscopic and direct visual control. They can be safely and repeatedly carried out if the sinus tract is kept open. Preoperative percutaneous transhepatic cholangioscopy is an important tool in the diagnosis and treatment of intrahepatic stones, because it provides the important information necessary for selection of an appropriate therapeutic procedure. Different stone extraction techniques can be accurately carried out with endoscopic guidance, and stones that are visible are readily removable. A good prognosis can be expected when stones are completely extracted. With this approach, the author believes that the results of treatment for intrahepatic stones will be significantly improved. Presented at the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

改良的经皮经肝胆道镜术治疗肝内胆管结石(附15例报告)

目的:探讨经皮经肝胆道镜术(PTCS)的新方法及其临床应用价值。方法:改良传统的PTCS方法,选择剑突旁入路。在经皮经肝胆管引流(PTCD)一周后,进行瘘道扩张并将隔离鞘套置入瘘道内,然后应用各种腔镜经鞘套进行胆道内碎石、取石、胆道扩张,置内支架治疗肝内胆管结石。就15例进行回顾性分析。结果:手术全部成功,完全取净率为86.7%(13/15),术后无胆瘘与出血并发症。结论:对部分肝内胆管结石,尤其是残留或复发结石及其伴随的胆道狭窄和阻塞性黄疸,改良的PTCS是一种创伤小、安全有效的术式。     

Use of Stone Cone minimizes stone migration during percutaneous nephrolithotomy

We describe a simple and effective method using the Stone Cone to prevent migration of stone fragments into the ureter during percutaneous nephrolithotomy. This maneuver may reduce the need for antegrade ureteroscopy to remove residual fragments, thereby saving time and obviating the need for placement of an occlusion balloon.     

ELISA法观察组织源性β-G在原发性肝内胆管结石中的变化

目的 观察组织源性β-G在原发性肝内胆管结石形成中的作用。方法 用高特异性单抗，采用ELISA方法检测肝组织匀浆和胆汁内的组织源性β-G。结果 PIS患者组肝细胞内β-G有轻度升高但未达到相差显著水平，胆汁内组织源性β-G与正常组比较无显著差别。结论 组织源性β-G在PIS发病过程中不起主要作用。     

Extracorporeal shock wave lithrotripsy of intrahepatic stones. Case presentation and review of the literature

Primary hepatolithiasis, although rare, is a difficult condition requiring the combined management of radiology and surgery. Use of extracorporeal shock wave lithotripsy and percutaneous stone extraction, along with improved biliary drainage by choledochojejunostomy, should provide a safe effective approach to this unusual problem.     

The role of endoscopic lithotomy in the treatment of intrahepatic stones

Although hepatolithiasis is a benign disease, its treatment is still the most difficult one in medical field. Before 1977, we had tried bilioenterostomy at the porta hepatis to expect spontaneous dislodgement of stones. However their results were very poor because of frequent occurrence of cholangitis which leads to hepatic failure or death in 8 of 15 patients. From 1977 to 1981, 35 patients had undergone postoperative cholangioscopy (POC). Complete stone removal was obtained in 24 patients. There were 13 difficult local problems in the remaining 11 patients including 6 being too narrow to permit the passage of the fiberscope, 3 having stones incarcerated, 3 having abnormal distribution of biliary tract and one being a missed stone. From 1981, we have carried out percutaneous transhepatic cholangioscopic lithotomy (PTCL) for the treatment of intrahepatic stones in 16 patients. Because abnormal distribution of biliary tract can be easily detected by PTC and incarcerated stones can be made into small pieces before removal following LASER application. We had succeeded in complete stone removal in 12 patients. 2 patients needed biliary reconstruction or liver resection after PTCL. We concluded that for treatment of the disease of intrahepatic stone PTCL should be considered as the first choice before surgery in order to avoid unnecessary hepatic resection or biliary reconstruction.     

术中输尿管镜气压弹道碎石治疗肝内胆管难治性结石53例报告

肝内胆管结石的治疗是目前肝胆外科的热点和难点,手术治疗方式繁多[1-3],2004年1月至2006年11月笔者对53例肝内胆管结石术中采用输尿管镜气压弹道碎石治疗,疗效满意,国内未见报道,现报道如下.