Extracorporeal shock wave lithotripsy for clearance of bile duct stones resistant to endoscopic extraction

BACKGROUND: Endoscopic extraction of bile duct stones after sphincterotomy has a success rate of up to 95%. Failures occur in patients with extremely large stones, intrahepatic stones, and bile duct strictures. This study examined the efficacy and the safety of extracorporeal shock-wave lithotripsy in a large cohort of patients in whom routine endoscopic measures including mechanical lithotripsy had failed to extract bile duct stones. METHODS: Out of 1587 consecutive patients, endoscopic stone extraction including mechanical lithotripsy was unsuccessful in 313 (20%). These 313 patients (64% women, median age, 73 years) underwent high-energy extracorporeal shock-wave lithotripsy. Stone targeting was performed fluoroscopically (99%) or by ultrasonography (1%). RESULTS: Complete clearance of bile duct calculi was achieved in 281 (90%) patients. In 80% of the patients, the fragments were extracted endoscopically after shock-wave therapy; spontaneous passage was observed in 10%. For patients with complete clearance compared with those without there were no differences with regard to size or number of the stones, intrahepatic or extrahepatic stone location, presence or absence of bile duct strictures, or type of lithotripter. Cholangitis (n = 4) and acute cholecystitis (n = 1) were the rare adverse effects. CONCLUSIONS: In patients with bile duct calculi that are difficult to extract endoscopically, high-energy extracorporeal shock-wave lithotripsy is a safe and effective therapy regardless of stone size, stone location, or the presence of bile duct stricture.     

Extracorporeal shock wave lithotripsy of bile duct stones: a single institution experience.

Extracorporeal shock wave lithotripsy treatment with Dornier HM3 or MPL 9000 machines was applied in 37 patients with problematic bile duct stones. General anaesthesia was not required. After one extracorporeal shock wave lithotripsy session 14/37 patients (38%) were spontaneously stone free, and additional endoscopic extraction (eight of 37) and retreatments with extracorporeal shock wave lithotripsy (seven cases) increased the stone free rate to 29/37 (78%). In three patients with intrahepatic stones, the bile ducts could not be evaluated decisively at cholangiography and ultrasonography, but they were all symptom free at 15 to 38 months follow up. If these three patients are added to the radiologically stone free patients, the overall clinical success rate was 32/37 (86%). There were no serious complications, hospital admissions, or 30 day mortality as a result of extracorporeal shock wave lithotripsy or endoscopic procedures. It is concluded that extracorporeal shock wave lithotripsy is a valuable adjunct to the non-surgical treatment of bile duct stones.     

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.     

Successful shock-wave lithotripsy of bile duct stones using ultrasound guidance

Eighteen patients with 41 gallstones in the common bile duct, common hepatic, cystic, and intrahepatic ducts underwent shock-wave lithotripsy using the electrohydraulic Sonolith 3000 lithotripter. Lithotripsy was performed using ultrasound guidance alone under intravenous analgesia/sedation. All patients previously had failed stone extraction via retrograde endoscopy, T-tube, or cholecystostomy., Lithotripsy was performed according to an FDA-approved protocol allowing a maximum of two 2500 shock-wave treatments at a 48 hr interval. Following the final lithotripsy or cholangiographic evidence of stone fragmentation, residual fragments were removed via endoscopic or percutaneous route within 24–72 hr. Ultrasound localization of gallstones was aided by continous infusion of the common bile duct with saline solution. In 15 of the 18 patients, complete fragmentation of the stones was accomplished, two had minimal fragmentation, and one with an encysted stone had no fracturing. No serious complications were encountered. Overall nonsurgical stone-free success rate was 17 of 18 patients, indicating biliary duct stones can be successfully treated using an ultrasound-guided lithotripter and intravenous sedation alone.     

Extracorporeal lithotripsy in the treatment of common bile duct calculi]

Thirty-three patients with common bile duct stones which could not be extracted by routine endoscopic measures were treated with extracorporeal lithotripsy. Two electrohydraulic lithotripters were used: Dornier HM3 and Technomed Sonolith 3000 using fluoroscopy and ultrasonography, respectively, for stone localisation. Twenty-nine patients were treated with only one session and four patients in two sessions. Fragmentation of stones was obtained in 29 patients (88 p. 100) and complete bile duct clearence in 26 patients (79 p. 100). The fragments passes spontaneously through the papilla in 7 cases; in 19 cases complete removal of fragments was achieved with a Dormia basket (16 cases) or after mechanical lithotripsy (3 cases). There were no significant differences in successful fragmentation rates between the two lithotriters. No serious adverse effects or mortality were observed within the 30 days following treatment. In conclusion, extracorporeal lithotripsy is an effective and safe method for the treatment of bile duct stones when, after sphincterotomy, routine endoscopic measures have failed.     

Difficult bile duct stones

Opinion statement Bile duct stones are routinely removed at time of endoscopic retrograde cholangiopancreatography (ERCP) after biliary sphincterotomy with standard balloon or basket extraction techniques. However, in approximately 10% to 15% of patients, bile duct stones may be difficult to remove due to challenging access to the bile duct (periampullary diverticulum, Billroth II anatomy, Roux-en-Y gastrojejunostomy), large (> 15 mm in diameter) bile duct stones, intrahepatic stones, or impacted stones in the bile duct or cystic duct. The initial approach to the removal of the difficult bile duct stone is to ensure adequate biliary sphincter orifice diameter with extension of biliary sphincterotomy or balloon dilation of the orifice. Mechanical lithotripsy is a readily available adjunct to standard stone extraction techniques and should be available in all ERCP units. If stone extraction fails with these maneuvers, two or more bile duct stents should be inserted, and ursodiol added to aid in duct decompression, stone fragmentation, and stone dissolution. Follow-up ERCP attempts to remove the difficult bile duct stones may be performed locally if expertise is available or alternatively referred to a tertiary center for advanced extracorporeal or intracorporeal fragmentation (mother-baby laser or electrohydraulic lithotripsy) techniques. Nearly all patients with bile duct stones can be treated endoscopically if advanced techniques are utilized. For the rare patient who fails despite these efforts, surgical bile duct exploration, percutaneous approach to the bile duct, or long-term bile duct stenting should be discussed with the patient and family to identify the most appropriate therapeutic option. A thoughtful approach to each patient with difficult bile duct stones and a healthy awareness of the operator/endoscopy unit limitations is necessary to ensure the best patient outcomes. Consultation with a dedicated tertiary ERCP specialty center may be necessary.     

Extracorporeal Piezoelectric Lithotripsy for Complicated Bile Duct Stones

Today, common bile duct stones are extracted endoscopically. After endoscopic sphincterotomy, nearly 90% of all stones can be removed with a Dormia basket or a mechanical lithotripter. Problems are encountered if there are larger stones or a duct stenosis. New conservative therapies do serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. Stone fragmentation can be achieved by extracorporeal shock wave lithotripsy, and remaining fragments can be removed endoscopically. So far, authors of most reports on the successful disintegration of common bile duct stones used the Dornier lithotripter. Stone localization is thus achieved with x-rays, and the shock waves are generated by an underwater spark discharge. We report on our experiences and results with extracorporeal piezoelectric shock wave lithotripsy (EPL) in 19 patients with complicated bile duct stones. With this lithotripter, stones are visualized by ultrasound, and shock waves are produced by a piezoelectric acoustic generator. Fragmentation was achieved in 84.2%, and complete stone removal in 78.9%. These results show that piezoelectric lithotripsy is also a useful method for the treatment of complicated bile duct stones, as has already been proved for the electrohydraulic- and electromagnetic-generated shock waves systems. However, the renunciation of general anesthesia and the need for analgesia or sedation in only 25% of the treatments render this lithotripter system attractive, especially for elderly and frail patients.     

Fragmentation of bile duct stones by extracorporeal shock waves. A new approach to biliary calculi after failure of routine endoscopic measures

A prospective uncontrolled multicenter trial was performed on 113 patients with bile duct stones in whom routine endoscopic approaches for removal of the calculi had failed. These represented 8.3% of the patients referred to the participating centers for endoscopic extraction of the stones. Extracorporeal shock-wave lithotripsy using the Dornier kidney lithotripter achieved stone disintegration in 103 patients (91%). Complete stone clearance from the bile ducts was obtained in 97 patients (86%) after a median of 4 days following extracorporeal shock-wave lithotripsy. Adverse effects, mostly mild, occurred in 36% of the patients. A 30-day mortality rate of 0.9% (in-hospital mortality rate = 1.8%) of this high-risk group with a mean age of 72 yr and a cholangitis rate of 26% compared favorably with the data given for open surgery. We therefore consider extracorporeal shock-wave lithotripsy a useful method for the treatment of bile duct stones not amenable to routine endoscopic measures.     

Biliary lithotripsy with a new electromagnetic shock wave source

During a two-year study period 170 consecutive patients with gallbladder stones, suitable for lithotripsy, were treated with a new electromagnetic lithotriptor (Modulith) and oral bile acids; 142 patients were treated as outpatients. Sufficient fragmentation were obtained in 94% when 2112±137 shocks in 211 sessions with an energy setting of 17.8±0.8 kV were administered. Only 4/170 patients needed transient analgesia. Overall, side effects were transient and mild, but three patients developed biliary pancreatitis, which was treated by endoscopic sphincterotomy in two of them. A total of 67/100 patients were free of stones after one year. Subgroup analysis showed that 80% of the patients (stone diameter 5–20 mm), 64% (20–30 mm) and 65% (multiple stones), respectively, can expected to be free of stones after 12 months. In addition, 25 patients with large, endoscopically not extractable common bile duct stones were treated by lithotripsy with the Modulith. After endoscopic placement of a nasobiliary tube, stone targeting was possible by ultrasonography in 14 patients and by fluoroscopy in another 11 cases. In 23 of the 25 patients (92%) stone clearance by endoscopy was achieved after application of 2516±565 shocks with an energy preset of 18 kV. One patient refused further endoscopic procedures after successful fragmentation and another required local stone dissolution therapy. Side effects occurred more frequently (P<0.05) after lithotripsy of bile duct stones than of gallbladder stones, but they were without major clinical relevance. The new lithotriptor Modulith thus enables safe and highly effective lithotripsy of gallbladder calculi on an outpatient basis. Moreover, the device also allows successful lithotripsy of bile duct stones.     

Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones

BACKGROUND: Mechanical lithotripsy is used to break large bile duct stones. This study investigated the predictors of unsuccessful mechanical lithotripsy. METHODS: Consecutive patients with bile duct stones underwent endoscopic retrograde cholangiography, sphincterotomy, and basket removal of stones. Mechanical lithotripsy was performed for stones of large size (>15 mm diameter) that precluded extraction intact. Success was defined as complete clearance of the duct. Various predictive factors, including size and number of stones, stone impaction, serum bilirubin, presence of cholangitis, and bile duct diameter were analyzed in relation to the success or failure of lithotripsy. RESULTS: A total of 669 patients underwent endoscopic retrograde cholangiography for suspected choledocholithiasis, which was found in 401 patients. Of the latter patients, 87 had large stones that required mechanical lithotripsy. Lithotripsy was successful in 69 (79%) patients. Impaction of the stone(s) in the bile duct was the only significant factor that predicted failure of lithotripsy and consequent failure of bile duct clearance. Other factors, including stone size, were not significant. CONCLUSIONS: Mechanical lithotripsy is successful in about 79% of patients with large bile duct stones. The only significant factor that predicts failure of mechanical lithotripsy is stone impaction in the bile duct.     

Endoscopic extraction of large common bile duct stones: A review article

Since therapeutic endoscopic retrograde cholangiopancreatography replaced surgery as the first approach in cases of choledocolithiasis,a plethora of endoscopic techniques and devices appeared in order to facilitate rapid,safe and effective bile duct stones extraction.Nowadays,endoscopic sphincterotomy combined with balloon catheters and/or baskets is the routine endoscopic technique for stone extraction in the great majority of patients.Large common bile duct stones are treated conventionally with mechanical lithotripsy,while the most serious complication of the procedure is "basket and stone impaction" that is predominately resolved surgically.In cases of difficult,impacted,multiple or intrahepatic stones,more sophisticated procedures have been used.Electrohydraulic lithotripsy and laser lithotripsy are performed using conventional mother-baby scope systems,ultra-thin cholangio-scopes,thin endoscopes and ultimately using the novel single use,single operator SpyGlass Direct Visualization System,in order to deliver intracorporeal shock wave energy to fragment the targeted stone,with very good outcomes.Recently,large balloon dilation after endoscopic sphincterotomy confirmed its effectiveness in the extraction of large stones in a plethora of trials.When compared with mechanical lithotripsy or with balloon dilation alone,it proved to be superior.Moreover,dilation is an ideal alternative in cases of altered anatomy where access to the papilla is problematic.Endoscopic sphincterotomy followed by large balloon dilation represents the onset of a new era in large bile duct stone extraction and the management of "impaction" because it seems that is an effective,inexpensive,less traumatic,safe and easy method that does not require sophisticated apparatus and can be performed widely by skillful endoscopists.When complete extraction of large stones is unsuccessful,the drainage of the common bile duct is mandatory either for bridging to the final therapy or as a curative therapy for very elderly patients with short life expectancy.Placing of more than one plastic endoprostheses is better while the administration of Ursodiol is ineffective.The great majority of patients with large stones can be treated endoscopically.In cases of unsuccessful stone extraction using balloons,baskets,mechanical lithotripsy,electrohydraulic or laser lithotripsy and large balloon dilation,the patient should be referred for extracorporeal shock wave lithotripsy or a percutaneous approach and finally surgery.     

Endoscopic biliary large-balloon dilation after endoscopic sphincterotomy for the treatment of large common bile duct stones. Case Report

Common bile duct (CBD) stones extraction is usually performed by endoscopic sphincterotomy followed by removal by either a Dormia basket or extraction balloon catheter. However, some stones due to their size are not amenable to these procedures and extracorporeal or mechanical lithotripsy devices need to be used. Mechanical lithotripsy involves usage of a basket that will be inevitably destroyed which increases cost to the patient and endoscopy unit. The use of extracorporeal wave shock lithotripsy is an alternative; however it is not available widely. Reports about the use of hydrostatic large caliber balloon dilator (HLCBD) aiding in the extraction of large caliber CBD stones have concluded that is a safe and feasible therapeutic alternative. We present the case of a 25 mm x 30 mm CBD stone that could not be extracted using conventional methods. CBD dilation using HLCBD was performed after endoscopic sphincterotomy in an attempt to avoid mechanical lithotripsy.     

Tonnenkonkremente – Besonderheiten beim Hochbetagten

Endoscopic sphincterotomy and stone extraction are established therapeutic procedures for common bile duct stones. Various nonsurgical techniques are available to increase the success rate, especially in patients with giant stones; these include mechanical lithotripsy, extracorporeal shock wave lithotripsy, intraductal lithotripsy, and percutaneous transhepatic procedures. Endoscopic intervention in the treatment of symptomatic common bile stones in elderly patients and especially in cases of giant bile duct stones is also safe and is not associated with a higher complication rate compared with the normal population.     

Endoscopic sphincterotomy for retained common duct stones

Twenty-one patients with retained stones after biliary surgery were managed by endoscopic sphincterotomy and stone extraction in the postoperative period. The bile duct was cleared of stones in 20 patients (95%). In one patient stone extraction was unsuccessful. There were no complications. Compared to percutaneous trans-T-tube tract stone extraction, endoscopic sphincterotomy does not require a 6 week waiting period. Endoscopic sphincterotomy should be considered for retained bile duct stones if endoscopic expertise is available.     

Fragmentation of bile duct stones by extracorporeal shock-wave lithotripsy: a five-year experience.

Over 5 yr, 103 elderly patients (mean age = 70 yr) with bile duct stones (mainly not amenable to endoscopic extraction) underwent adjuvant extracorporeal shock-wave lithotripsy using a first-generation kidney lithotripter. Disintegration of stones was achieved after a mean of 1.4 sessions in 92% of the patients. Spontaneous passage of fragments into the duodenum occurred in one fourth of the patients, and endoscopic extraction of fragments was necessary in 75% of the patients, resulting in complete clearance of the bile duct stones in 91 (88%) of 103 patients. The most important adverse effect was septic disease after extracorporeal shock-wave lithotripsy in 4% of the patients. The 30-day mortality rate was 1% (one patient), and another 15 patients died during a mean follow-up of 26 +/- 14 mo (mainly of causes unrelated to biliary tract disease). Two of 91 patients who had been rendered stone free were readmitted because of recurrent stone disease during the follow-up period. Of the 43 patients who still had their gallbladders during extracorporeal shock-wave lithotripsy, 14% subsequently underwent cholecystectomy. These data show that extracorporeal shock-wave lithotripsy of bile duct stones is a useful and safe adjunct to nonsurgical procedures for the removal of calculi in the biliary tree.     

Endoscopy for bile duct stones

In the era of laparoscopic cholecystectomy and advanced non-invasive imaging studies, pre-operative endoscopic retrograde cholangiopancreatography (ERCP) for bile duct stones should be reserved for selected patients. ERCP remains the therapy of choice for removal of bile duct stones in the post-cholecystectomy patient and in patients with intact gallbladders. Bile duct stones can be cleared in nearly all patients using endoscopic techniques of sphincterotomy and mechanical lithotripsy. Difficult or complex bile duct stones can be endoscopically removed in the majority of patients with additional techniques such as extracorporeal shock wave lithotripsy, intraductal lithotripsy and/or stent placement. In non-operative patients in whom stone clearance cannot be achieved, long-term stent placement is a potential option in patients who are not candidates for further therapy. Endoscopic therapy may be effective in selected patients with intrahepatic biliary stones.     

Endoscopic treatment of pancreatic duct stones using a 10F pancreatoscope and electrohydraulic lithotripsy

BACKGROUND: Endoscopic therapy with adjunctive extracorporeal shock wave lithotripsy fails to provide clearance of pancreatic duct stones in up to 25% of symptomatic patients. Direct contact lithotripsy may provide an additional option for removal of refractory stones. We report our initial experience using a prototype 10F "baby" endoscope to administer electrohydraulic lithotripsy. METHODS: Five patients failing extracorporeal shock wave lithotripsy and one patient with recurrent pancreatic duct stones after surgery were selected to undergo endoscopic electrohydraulic lithotripsy. After pancreatic sphincterotomy and balloon dilation (8 or 10 mm), the 10F endoscope was introduced and electrohydraulic lithotripsy was used to fragment stones under direct visualization. RESULTS: Six patients underwent 9 intraductal electrohydraulic lithotripsy procedures. Complete or partial pancreatic duct clearance was accomplished in all but one. No complications from the lithotripsy procedure were noted. The 5 patients with partial or complete duct clearance experienced complete relief of abdominal pain of at least 6 months' duration following their final procedure. CONCLUSION: Electrohydraulic lithotripsy within the pancreatic duct provides an adjunctive endoscopic option for treatment of patients with symptomatic pancreatic duct stones. Our initial experience suggests that electrohydraulic lithotripsy therapy can successfully fragment stones refractory to conventional endoscopic stone extraction methods or extracorporeal shock wave lithotripsy. Further experience is necessary to establish the risks of electrohydraulic lithotripsy within the pancreatic duct.     

Therapy of choledocholithiasis using extracorporeal shock wave lithotripsy and adjuvant surgical endoscopy]

Extracorporeal shock wave lithotripsy of extra- and intrahepatic bile duct stones is indicated after failure of conventional operative endoscopic procedures including mechanical lithotripsy. An overview of the current literature (12 centers, 568 patients) indicates that this novel procedure has attracted international acceptance. It was applied in elderly patients (means = 65 years) with solitary (37.5%) or multiple (62.5%) concrements. Clearance of the bile ducts was achieved in 71.6% after 1.3 to 3.0 lithotripsy sessions (1900-4000 shocks) if additional endoscopic sphincterotomy was performed. Without sphincterotomy 61% of patients were treated successfully. The most frequent side effects were macrohematuria (6.9%), hemobilia (6.2%) cholangitis (4.5%) and pancreatitis (1.3%). A lethality of 0-3.6% (means = 0.6%) was reported. The current results demonstrate that therapy of extra- and intrahepatic bile duct stones with extracorporeal shock wave lithotripsy is effective, safe and provides high therapeutic comfort.     

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.     

A Case of Pancreatolithiasis Treated by a Combination of Endoscopic Extraction and Extracorporeal Shock Wave Lithotripsy

We report on the case of a 50-year-old woman with idiopathic chronic calcifying pancreatitis and diabetes. An endoscopic retrograde pancreatography showed a stone with a diameter of 23 mm and multiple small stones in the head of the pancreas. An endoscopic pancreatic sphincterotomy was performed. However, the stone could not be removed endoscopically. So we performed an extracorporeal shock wave lithotripsy (ESWL) using a Tripter X1. The stone was located in the shock wave focus by fluoroscopy. Under intravenous sedation, the patient received 5 ESWL sessions (a total of 11700 shock waves with an energy of 18kv). ESWL permitted stone disintegration and successful endoscopic extraction of the fragments. Complete clearance in the main pancreatic duct was achieved. No severe complications were observed. After treatment, an improvement in the PFD test was seen. ESWL is an effective method for treatment of endoscopically unextractable pancreatic ductal stones.