Management of complex biliary tract calculi with a holmium laser |
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Authors: | Peter Shamamian Michael Grasso |
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Institution: | (1) Department of Surgery, New York University School of Medicine, 550 First Avenue, Suite 6B, 10016 New York, NY;(2) Department of Surgery, Bellevue Hospital Center, New York, New York;(3) Department of Surgery, The Veterans Administration New York Harbor Healthcare System, New York, New York;(4) Department of Urology, Saint Vincent’s Medical Center, New York, New York;(5) Department of Urology, New York Medical College, New York, New York |
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Abstract: | The difficulty in managing complex biliary tract calculi is exemplified in patients with primary intrahepatic calculi. Standard
surgical and endoscopic approaches often fail to clear calculi in these patients who have recurrent episodes of cholangitis.
The success of the holmium laser for urologic calculi led us to adapt treatment strategies for primary and secondary biliary
tract calculi where standard treatments had been unsuccessful. Our goals were to remove all calculi, prevent recurrent sepsis,
and preserve hepatic parenchyma. Thirty-six patients with complex biliary calculi were treated. After sepsis was controlled
and the extent of calculi was evaluated, appropriate access to and drainage of the biliary tract was achieved. Holmium laser
lithotripsy was performed under video guidance using flexible choledochoscopes and a 200 μ laser fiber generating 0.6 to 1.0
joules at frequencies of 6 to 10 Hz. Lithotripsy procedures were repeated until cholangiography and cholangioscopy confirmed
the clearance of calculi. Twenty-two patients of Asian descent with primary intrahepatic calculi and 14 patients with secondary
intrahepatic calculi were treated. Access to the biliary tract could be accomplished through percutaneous catheter tracts,
T-tube tracts, or the cystic duct during laparoscopic cholecystectomy. Biliary drainage was by biliary enteric anastomosis
or endoscopic sphincterotomy. Complete stone clearance required an average of 3.9 procedures (range 1 to 15) for patients
with primary intrahepatic calculi and 2.6 procedures (range 1 to 10) for patients with secondary intrahepatic calculi regardless
of stone composition. No patient required hepatic resection and no complications or deaths were attributed to the holmium
laser. Clearance of calculi can reliably and safely be achieved with a holmium laser regardless of stone composition or location
while preserving hepatic parenchyma and preventing recurrent sepsis.
Presented at the Fourth Americas Hepato-Pancreato-Biliary Association Congress, Miami Beach, Florida, February 27-March 2,
2003. |
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Keywords: | Bile duct hepatolithiasis cholangiohepatitis bile duct calculi cholangitis laser lithotripsy |
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