Removal of a Large Common Bile Duct Stone Using Endoscopic Balloon Sphincter Dilation and Extracorporeal Shock Wave Lithotripsy

Abstract: Although endoscopic balloon sphincter dilation (EBSD) appears to be an attractive treatment modality, the rate of bile duct clearance is apparently reduced due to limited enlargement of the bile duct opening when the stones are large and/or numerous. We present the case of an 87-year-old woman who developed an extremely large bile duct stone. To crush the stone sufficiently to allow grasping by a mechanical lithotriptor or a basket catheter with the EBSD procedure, extracorporeal shock wave lithotripsy was performed and the fragments were removed successfully.     

Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct. The mean number of lithotripsy sessions was less in the EHL group (1.4 vs 2.3). There were no major differences in average hospital stay, 30-day mortality was zero in both groups. Combined treatment including EPL, EHL, and intracorporeal laser lithotripsy was finally successful in 32 patients (91.5%). It is concluded that EHL might be the method of choice for smaller, single stones in the more proximal parts of the common bile duct. In these cases, complete duct clearance in one lithotripsy session can be achieved. Multiple and large stones are probably best accessible to EPL. With a combination of the methods described, the bile duct can be cleared of concrements in almost every instance. As a result, surgery for choledocholithiasis has become the absolute exception.This work was presented in part at the 1993 Annual Meeting of the american Gastroenterological Association in Boston and published in abstract form (Gastroenterology 104:A347, 1993).     

Stenting and Extracorporeal Shock Wave Lithotripsy in Chronic Pancreatitis

Background: Early observational studies of endoscopic treatment and extracorporeal shock wave lithotripsy (ESWL) reported considerable or complete relief of pain in 50%-80% of patients with chronic pancreatitis. There is no consensus on the measurement of pain, making comparison of observational studies difficult, and little attention has been paid to the type and amount of analgesics used by patients before and after decompressive treatment. Methods: We performed a retrospective study of all patients with chronic pancreatitis and large-duct disease and receiving decompressing treatment between 1 November 1994 and 31 July 1999. Primary parameters were type and amount of analgesics used. Results: Forty-nine patients with chronic pancreatitis and large-duct disease received stenting of the pancreatic duct (28 patients), ESWL (6 patients) or both (15 patients). After a median follow-up of 21 months, 35% of all patients were pain-free and a further 6% were not using analgesics. Seven patients no longer needed opioids during follow-up, but five other patients needed addition of opioids to treatment. The median opioid dose among opioid-dependent patients rose slightly (9%). The median increase of weight after treatment was 1 kg per year. Conclusion: After decompressive treatment of patients with chronic pancreatitis and large-duct disease, we observed a small increase in weight and a small reduction in the number of opioid users. The changes may not be different from the natural course of the disease.     

Clinical Features and Outcomes of Endoscopic Treatment for Stones in Stemware-Shaped Common Bile Ducts: A Multicenter Data Analysis

Background/Aims

Various anatomical features of the biliary tree affect ability to remove difficult common bile duct (CBD) stones. In this study, we evaluated the clinical characteristics and outcomes of the endoscopic treatment of stones in stemware-shaped CBDs.

Methods

Thirty-four patients with a stone and a stemware-shaped CBD who were treated at different tertiary referral centers from January 2008 to December 2012 were studied retrospectively. When stone removal failed, percutaneous or direct peroral cholangioscopic lithotripsy, endoscopic retrograde biliary drainage, or surgery was performed as a second-line procedure.

Results

The overall success rate of the first-line procedure was 41.2%. Five of the 34 patients (14.7%) experienced procedure-related complications. No procedure-related mortality occurred. Mechanical lithotripsy was required to completely remove stones in 13 patients (38.2%). Conversion to a second-line procedure was required in 20 patients (58.8%). Mechanical lithotripsy was needed in 75% and 66.7% of those with a stone size of <1 cm or ≥1 cm, respectively. Stone recurrence occurred in two patients (9.1%) after 6 months and 27 months, respectively.

Conclusions

The endoscopic treatment of stones in a stemware-shaped CBD is challenging. The careful assessment of difficult CBD stones is required before endoscopic procedures.     

The Visceral-to-subcutaneous Adipose Tissue Area Ratio Is Associated with Retreatment in Chronic Pancreatitis Patients with Pancreatolithiasis after Extracorporeal Shock Wave Lithotripsy

Objective Extracorporeal shock wave lithotripsy (ESWL) has been used to treat pancreatolithiasis in patients with chronic pancreatitis (CP), but the high recurrence rate remains challenging. We therefore evaluated the association between body composition parameters and the prediction of retreatment after ESWL. Methods This study retrospectively evaluated 42 patients with CP who had been treated with ESWL between 2008 and 2019 in a single center. Body composition parameters were measured on pretreatment computed tomography images. Patients who underwent repeat ESWL were classified as the retreatment group. Results There were 13 (31.0%) and 29 (69.0%) patients in the retreatment and non-retreatment groups, respectively. The visceral-to-subcutaneous adipose tissue area ratio (VSR) of the retreatment group was significantly lower than that of the non-retreatment group (p=0.016). When divided by the median VSR, 10 of the 20 patients with a VSR of ＜0.85 underwent retreatment, whereas 3 of the 22 patients with a VSR of ≥0.85 underwent retreatment (p=0.019). According to a multivariate analysis, the VSR (p=0.010) and age (p=0.037) were independent factors associated with retreatment after ESWL. Conclusion This study showed that the VSR can predict the retreatment of patients with CP after ESWL.     

Laser lithotripsy of difficult bile duct stones: results in 60 patients using a rhodamine 6G dye laser with optical stone tissue detection system

^a Department of Surgery, Utrecht University Hospital, Utrecht, The Netherlands, ^b Department of Gastroenterology

Correspondence to: Professor L M A Akkermans, Department of Experimental Surgery, Gastrointestinal Motility Unit, Utrecht University Hospital, PO Box 85500-3508 GA, Utrecht, The Netherlands.

Accepted for publication 18 December 1997

Background—Studies have shown that an altered visceral perception threshold plays a role in the pathogenesis of upper gastrointestinal tract symptoms in dyspeptic patients. However, it is not clear whether the compliance and adaptive relaxation of the proximal stomach contribute to the symptoms.
Aims—To investigate whether abnormal relaxation or adaptation of the proximal stomach during the interdigestive state and the postprandial phase could explain the symptoms of functional dyspepsia.
Subjects—Twelve volunteers and 12 patients with dysmotility-like functional dyspepsia were included in the study.
Methods—An electronic barostat was used to investigate adaptation to distension of the proximal stomach and accommodation in response to a liquid meal. Dyspeptic symptoms during distension and accommodation were assessed.
Results—When the subjects were in the fasting state, the pressure-volume curve showed slightly higher compliance in the dyspeptic patients (p<0.05). Patients not only had a higher score for nausea, bloating, and pain but also the increase in nausea and pain scores with intragastric pressure was higher than in volunteers (p<0.05). The increase in intragastric bag volume in response to a meal was significantly lower in patients (p<0.05). Both bloating and pain significantly increased in the patients (p<0.05), but not in the healthy volunteers.
Conclusions—Patients with functional dyspepsia show slightly higher compliance to mechanical distension. Their visceral perception of mechanical stress is enhanced. In contrast with the balloon distension, relaxation after a meal was less. Therefore the postprandial symptoms cannot be explained fully by greater global tension in the stomach wall, as assessed by the barostat technique. Visceral hypersensitivity plays a major role in the pathogenesis of the symptoms.
(GUT 1998;:823-829)

Keywords: dyspepsia;  gastric distension;  gastric accommodation;  gastric sensitivity

     

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

Background/AimsThis study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi.MethodsA total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records.ResultsBiliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8).ConclusionsAlthough periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.     

Analytical and Numerical Modeling of Stress Field and Fracture in Aluminum/Epoxy Interface Subjected to Laser Shock Wave: Application to Paint Stripping

In this paper, analytical and numerical models have been developed to compute the stress field and predict fracture of the aluminum/epoxy interface subjected to laser shock loading, in the frame of the investigation of the paint stripping process. An explicit finite element (FE) model combined with the cohesive zone modeling (CZM) method, an analytical stress analysis model, and a spall fracture model have been developed. The numerical model has been calibrated and validated against tests in terms of the stripping pattern, while the analytical models have been compared with the numerical model. The models were combined to generate computational tools for decreasing computational effort. The FE model with the CZM is the most accurate tool although it is the most computationally expensive. The spall fracture model gives trusted estimations of the spall strength of the interface which are very sensitive to the interface thickness and when incorporated into a continuum FE-based damage model can predict the stripping initiation faster than the FE model with the CZM. The analytical stress analysis model can be used to efficiently describe the shock wave propagation into the material system, but it can give only a rough estimation of the tensile stress at the epoxy, which when combined with the spall strength does not give reliable predictions of the stripping initiation. The three models require as input different material properties, some of which are very difficult to determine. Nevertheless, the availability of accurate material parameters and properties of the aluminum, the epoxy, and, especially, their interface can significantly improve the efficiency of the developed models.     

Bile duct cyst type V (Caroli's disease): surgical strategy and results

Background. Caroli''s disease (CD) is a benign congenital disorder characterized by segmental cystic dilatation of the intrahepatic biliary ducts. Therapeutic strategy includes medical treatment, percutaneous, endoscopic or surgical drainage of the affected bile ducts, liver resection or transplantation. The aim of this study was to analyse the results and long-term follow-up of a consecutive series of patients who underwent surgical treatment for CD. Patients and methods. Between 1995 and 2005, 10 patients were surgically treated for CD. Variables evaluated were: age, gender, clinical presentation, diagnostic procedures, percutaneous and surgical treatments, histopathological analysis and outcome. Results. The average age of the patients was 45.8 years. Recurrent cholangitis was the main clinical manifestation (70%). In unilateral CD a liver resection was performed in nine patients (left lateral sectionectomy in seven, left hepatectomy in one and right hepatectomy in one). In bilateral disease a cholecystectomy, duct exploration, hepaticojejunostomy and liver biopsy of both lobes were performed. Average follow-up was 60 months. All the patients are alive and free of symptoms without recurrence in the remnant liver. Discussion. Liver resection is the preferred therapeutic option for unilateral CD, demonstrating good results in long-term follow-up. In bilateral disease, hepaticojejunostomy could be considered as an alternative or a previous step to liver transplantation, which still remains the ultimate option.     

Reduction of pre-procedural anxiety for repeat sessions in extracorporeal shockwave lithotripsy (ESWL) reduces pain intensity: A prospective observational study

Pain control is a major determinant for successful stone clearance in extracorporeal shockwave lithotripsy (ESWL) for urolithiasis. Pain perception during ESWL may be influenced by patient factors like gender, age, body habitus and anxiety level, and stone related factors like size, laterality and location of stone. We investigated in general, the confounding patient and stone factors influencing pain perception during ESWL with importance given to procedural anxiety in first and the subsequent session of ESWL. This was a prospective observational study of all new consecutive patients who underwent ESWL for a period of 1 year at a tertiary Urological Centre. Demographic and stone anthropometry were analyzed. Pre-procedural anxiety was assessed prior to procedure using hospital anxiety and depression score (HADS) and pain was scored using numerical rating scale-11 at baseline, 30-minutes (i.e., during) and 24 hours after ESWL. Univariate and multivariate analysis for confounding factors included HADs were performed for pain perception. A P value < .05 was considered to be statistically significant. For the study duration, 119 patients were recruited and 72 of them returned for a second session. Procedural anxiety was the only independent factor affecting pain score in ESWL for the first session in multivariate analysis. A statistically significant reduction of mean procedural anxiety score from 6.7 ± 4.5 to 3.2 ± 2.7 (P < .05) for the second ESWL session was observed (n = 72). This was in conjunction with statistical reduction of mean pain score 30 minutes after ESWL from 5.2 ± 2.1 to 4.2 ± 2.1 (P < .05). Patients with HADS ≥ 8 had statistically significant higher mean pain score at all 3 intervals in the first ESWL session. This study has shown that pre-procedural anxiety mainly anticipatory, reduces and shows reduction in pain intensity among patients undergoing repeat ESWL. Hence, anxiety reducing methods should be explored in patients undergoing ESWL to avoid unnecessary analgesic use.     

Right Ventricular Dysfunction in Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Hemodynamic Analysis of the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock (SHOCK) Trial and Registry

Background

The prevalence and significance of right ventricular dysfunction (RVD) in patients with cardiogenic shock due to acute myocardial infarction (AMI-CS) have not been well characterized. We hypothesized that RVD is common in AMI-CS and associated with worse clinical outcomes.