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.     

Extracorporeal shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy is a new technique for treatment of symptomatic renal and upper ureteral calculi. After biplanar fluoroscopic localization of the targeted calculus, serial shock waves cause calculus disintegration, with subsequent spontaneous transurethral passage of the fragments. Excellent clinical results and patient enthusiasm have resulted. Physicians using extracorporeal shock-wave lithotripsy must also be adept at percutaneous, ureteroscopic, and standard surgical stone removal methods to deal with complex clinical stone presentations.     

Percutaneous management of bile duct stones

This article presents a review of the interventional radiological procedures in the percutaneous management of the bile duct stones through T-tube or transhepatic tracts. Interventional stone removal techniques mainly include extraction through the T-tube tract with baskets or forceps and expulsion into the duodenum by means of baskets or balloon catheters with the dilatation of the sphincter of Oddi. Fragmentation or size reduction of the stone, dilatation of the strictures and cholangioscopic assistance can facilitate the procedures.     

Extracorporeal shock-wave lithotripsy: prevalence of renal stones 3-21 months after treatment

One hundred and four (70%) of the first 148 patients who underwent extracorporeal shock-wave lithotripsy (ESWL) at the University of Florida were evaluated for persistent or recurrent renal stone disease. Radiographs obtained 3-21 months after treatment showed that 53 (50%) of 106 treated kidneys were free of stones. In 48 of the 53 kidneys that contained stones, the stones were residual fragments dating from the period immediately after ESWL. New stones had developed in only five kidneys. The 50% incidence of stone-free kidneys 3-21 months after ESWL is less than the 65-90% rate reported by other institutions in the United States and Europe. After stone removal by ESWL, new stone formation occurs at a rate of 5%, which is much lower than the expected recurrence rate of 37-50%.     

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.     

Sonographic evaluation of renal stones treated by extracorporeal shock-wave lithotripsy

Real-time sonography was performed on 94 patients the day before and at 24 and 48 hr after extracorporeal shock-wave lithotripsy (ESWL) therapy. The ability of sonography to detect renal stones before ESWL, changes in the calculi after ESWL, and the occurrence of pre- and post-ESWL hydronephrosis was evaluated. Abdominal radiographs and linear renal tomography were used as the standard of comparison. Six other patients had sonography only either before or after ESWL. One hundred patients had a total 105 kidneys treated; 18 kidneys with more than three stones were not included. The other 87 kidneys had 102 stones evaluated by sonography before having ESWL; 66 stones (65%) were identified and 36 were not. Of those calculi not seen, 10 were less than or equal to 5 mm in diameter. Nineteen of the other 26 stones were in the ureter or at the ureteropelvic junction. Comparison of sonograms of 80 kidneys obtained before and after ESWL revealed no change in 37 (46%), more stones or fragments detected in 23 (29%), fewer stones or a change in location in 12 (15%), and an apparent decrease in the size of the original stone in eight (10%). Hydronephrosis was detected by pre-ESWL sonography in 16 kidneys (20%) and was noted to develop after ESWL in 20 (31%) of the 64 other kidneys. These results indicate that the ability of sonography to detect renal calculi is related not only to stone size but also to location. The clinical significance of pre- and post-ESWL hydronephrosis found by sonography must be considered in conjunction with the patient's symptoms, laboratory data, and other radiographic studies. Therefore, the routine use of sonography in the post-ESWL patient does not seem warranted.     

Treatment of bile duct stones: value of laser lithotripsy delivered via percutaneous endoscopy

Extraction of stones from the bile ducts via standard endoscopic techniques, a percutaneous transhepatic approach, or a T-tube track can be unsuccessful. We report our preliminary experience with a combination of percutaneous cholangioscopy and dye laser lithotripsy. Flash lamp-excited dye laser (504 nm) lithotripsy delivered by percutaneous cholangioscopy (12 F) was evaluated in 13 patients with stones in the bile ducts. Conventional endoscopic treatment had not been attempted in 4 patients after hepaticojejunostomy and had failed in 3 patients after gastric bypass surgery or gastrectomy, and in 6 patients because of technical difficulties, i. e. due mainly to largeness of stones. In 12 patients a percutaneous transhepatic route was used. In 1 patient the T-tube track was used as access to the bile ducts. Laser lithotripsy resulted in successful fragmentation of stones in 12 patients (92%). The bile ducts cleared spontaneously in 2 patients only. Using additional techniques, i. e. sphincterotomy and stent insertion, the overall combined success rate for duct clearance after laser fragmentation was 100%. Four patients had a retrograde endoscopic sphincterotomy after failed attempts for stone removal at endoscopic retrograde cholangioscopy. Two patients had an antegrade fluoroscopically monitored sphincterotomy. Bleeding complications occured in 2 patients. This accounted for a high rate (15%) of severe complications. The intrahepatic bleeding in 1 patient was due to an intrahepatic vessel injury by the 13-F sheath. The periampullary bleeding in the other patient occurred after an antegrade papillotomy. Pulsed dye laser lithotripsy proved to be an effective technique in patients with difficult bile duct stones. The main problem of a percutaneous approach is the complete removal of the fragmented stones, which requires additional procedures in most cases. The percutaneous access is time-consuming and bears a relatively high risk of major bleeding complications. It should therefore be restricted to cases in which conventional endoscopic procedures are impossible or unsuccessful. Correspondence to: H.-J. Brambs     

Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients

Percutaneous, transhepatic, intracorporeal, electrohydraulic shock wave lithotripsy was performed in 50 patients after failure of endoscopic treatment (n = 43) or directly in patients with a strictured hepaticojejunostomy (n = 7). Twenty-seven patients had common bile duct stones; 23, intrahepatic stones. Three steps were used: A transhepatic bilicutaneous fistula was created, a wide communication between the bile duct and the gut was established, and contact shock wave lithotripsy was performed under endoscopic guidance. Afterward, 46 patients were free of stones. In four patients with diffuse intrahepatic lithiasis, only 75% of stones could be cleared. Severe complications, seen in 11 patients (hemobilia necessitating transfusion [n = 6], bile duct perforation resulting in cholangitis [n = 3], acute pulmonary edema [n = 1], and hemothorax [n = 1]), were fatal in four patients; all occurred early in the study. The authors modified their technique by dilating the biliary tract in two sessions 3 days apart, waiting 6 days for the tract to mature, and then introducing the cholangioscope directly through the skin, significantly reducing complications and mortality (P less than .005).     

闽北地区肝胆管结石细菌感染耐药情况分析

目的探讨闽北地区肝胆管结石患者胆汁的细菌谱及细菌药物敏感性状况。方法对我院自2008年7月—2012年7月收治的330例肝胆管结石的患者进行胆汁细菌培养及药物敏感性试验,并对收集的资料进行统计学分析。结果 330例患者中198例培养阳性,阳性率为60%。共培养菌株207株,其中G-菌126株,占60.9%,G+菌81株,占39.1%。引起胆道感染较为常见的菌属依次为大肠埃希菌属、粪肠球菌属、肺炎克雷伯菌属、铜绿假单胞菌属。G-菌对头孢他啶、头孢哌酮钠-舒巴坦钠、亚胺培南、阿米卡星敏感性较高,G+菌对氨曲南、亚胺培南敏感性较高。结论随着闽北地区各种抗菌药的广泛应用,肝胆管感染细菌谱发生了一定变化,G+菌比例虽有所上升,但G-菌仍占较高比例,且细菌对抗菌药的耐药性有所上升,临床应根据培养结果合理应用抗菌药。     

Optimal cholangiographic technique for detecting bile duct stones

Twenty-eight patients with proven bile duct stones were evaluated during either operative or T-tube cholangiography. Two radiographs were obtained for each patient without changing patient position between films. The first was performed with low peak kilovoltage (75-80 kVp) and 15% iodinated contrast medium and the second with high kVp (110) and 38% iodinated contrast. Seven radiologists evaluated the radiographs individually and in matched pairs for ductal filling, ductal penetration, motion unsharpness, overall quality, and stone detectability. The high-kVp radiographs were rated significantly better overall than the low-kVp studies (p less than 0.001) for all five criteria. In the second evaluation, which compared the pairs from the same patients, the 28 high-kVp radiographs were considered superior to the 28 low-kVp studies by the radiologists in almost two-thirds of the comparisons (ductal filling, 68%; penetration, 59%; less motion unsharpness, 65%; overall quality, 77%; stone detection, 62%). On the basis of the results of this study, high-kVp technique with full-strength contrast medium for operative and T-tube cholangiography is recommended.     

Detection of common bile duct stones by hepatobiliary scintigraphy

Hepatobiliary scintigraphy and direct X-ray cholangiography were compared in 29 patients with common bile duct (CBD) stones confirmed at surgery. The scintigraphic findings included no visualization of the biliary system (NV), pooling of bile in the biliary system (PB), prolonged transit time over 60 min (PTT), filling defect in the CBD image (FD), and reflux of bile toward the intrahepatic ducts after gallbladder stimulation (RB). The positive rates of NV, PB, PTT, FD, and RB in patients with CBD stones were 7%, 31%, 17%, 48%, and 14%, respectively. One or more of these five findings was found in 83%. Although the NV was a useful finding suggesting complete obstruction of the CBD, it shared little in the diagnosis of CBD stone. The positive rate of the PB was relatively high and it would be a useful finding as an indication of the presence of passage disturbance of the CBD. The PB was usually accompanied by the FD. The PTT had some usefulness in the detection of incomplete obstruction of the CBD in patients with a visualized gallbladder. In patients with no visualization of the gallbladder, however, the transit time tended to be shorter than that of gallbladder visualized patients. Therefore, the judgment of PTT in patients with no visualized gallbladder needed another criteria. The FD was the most frequent among the five findings and the sites of FD correlated well with CBD stones on direct X-ray cholangiography. The FD would be a reliable finding indicating CBD stone or CBD stenosis. Although the RB was a finding limited in patients with a visualized gallbladder, it seemed to be a helpful findings for the detection of CBD stone in patients with a mildly dilated CBD.     

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     

The misdiagnosis of common bile duct stones with ultrasound

Ultrasound is now widely used to demonstrate the presence of gall-stones in the gall bladder and common bile duct in jaundiced patients. The ultrasound appearance of gall-stones is characteristic and consists of strong, bright reflections with shadowing distally, though stones smaller than 3 or 4 mm may not always show shadowing. We report our experience with large common bile duct stones which do not show the characteristic features of gall-stones and so may be misdiagnosed as tumour masses. The possible reasons for these appearances are discussed.     

胆总管结石取石后复发结石的内镜再治疗

目的：观察内镜对胆总管结石取石后复发结石的治疗效果。方法：选择经上腹部CT或磁共振胰胆管成像（medical rehabititation center of pennsylvania,MRCP）证实、内镜下行胰胆管造影（endoscopic retrograde cholangiopancreatography,ERCP）术后胆总管再发结石48例,均经十二指肠乳头括约肌切开术（endoscopic sphincteropapillotomy,EST）,十二指肠乳头球囊扩张术（endoscopic papillo-sphincter balloon dilatation,EPBD）或EST＋EPBD后网篮或球囊取石。结果：48例中44例经内镜取石成功,手术时间为15-56min,平均29min。无一例并发症发生。结论：内镜治疗胆总管结石后可再发结石,经内镜再次取石是治疗EST术后胆总管结石复发的首选方法,安全有效。     

Preoperative evaluation of common bile duct stones in patients with gallstone disease

OBJECTIVE: Our objective was to suggest criteria for selection of a preoperative diagnostic technique for patients with gallstone disease. CONCLUSION: Use of MR cholangiography preferentially before laparoscopic cholecystectomy, on patients who have a moderate or high risk of common bile duct stones, can significantly reduce purely diagnostic endoscopic retrograde cholangiography.