Management of giant common bile duct stones in high-risk patients using a combined transhepatic and endoscopic approach
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Endoscopic retrograde laser lithotripsy of common bile duct stones is a new technique which can be carried out through the endoscope without anaesthesia using ordinary endoscopic equipment. In the method described here a flashlamp pulsed Neodymium YAG laser (wave length 1064 nm) was used. Light energy was transmitted along a highly flexible quartz fibre with a diameter of 0.2 mm. This new technique was used in nine patients with concrements in the common bile duct, which could not be removed with the established endoscopic techniques. In eight of the nine the concrements (maximum diameter 4.7 x 3.1 cm) could be fragmented and in six the fragments could be extracted from the common bile duct. The total energy required was 80-300 J; complications were not observed.
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AIM:The usual bile duct stone may be removed by means of Dormia basket or balloon catheter, and results are quite good.However, the degree of difficulty is increased when stones are larger.Studies on the subject reported many cases where mechanical lithotripsy is combined with a second technique, e.g., electrohydraulic lithotripsy (EHL), where stones are crushed using baby-mother scope electric shock.The extracorporeal shock-wave lithotripsy (ESWL) or laser lithotripsy also yields an excellent success rate of greater than 90%.However, the equipment for these techniques are very expensive; hence we opted for the simple mechanical lithotripsy and evaluated its performance. METHODS:During the period from August 1996 to December 2002, Mackay Memorial Hospital treated 304 patients suffering from difficult bile duct stones (stone >1.5 cm or stones that could not be removed by the ordinary Dormia basket or balloon catheter).These patients underwent endoscopic papillotomy (EPT) procedure, and stones were removed by means of the Olympus BML-4Q lithotripsy.A follow-up was conducted on the post-treatment conditions and complications of the patients. RESULTS:Out of the 304 patients, bile duct stones were successfully removed from 272 patients, a success rate of about 90%.The procedure failed in 32 patients, for whom surgery was needed.Out of the 272 successfully treated patients, 8 developed cholangitis, 21 developed pancreatitis, and 10 patients had delayed bleeding, and no patient died.Among these 272 successful removal cases, successful bile duct stone removal was achieved after the first lithotripsy in 211 patients, whereas 61 patients underwent multiple sessions of lithotripsy.As for the 61 patients that underwent multiple sessions of mechanical lithotripsy, 6 (9.8%) had post-procedure cholangitis, 12 (19.6%)had pancreatitis, and 9 patients (14.7%) had delayed bleeding.Compared with the 211 patients undergoing a single session of mechanical lithotripsy, 3 (1.4%)had cholangitis, 1 (0.4%) had delayed bleeding, and 7 patients (3.3%) had pancreatitis.Statistical deviation was present in post-procedure cholangitis, delayed bleeding, and pancreatitis of both groups.CONCLUSION: Mechanical bile stone lithotripsy on difficult bile duct stones could produce around 90% successful rate.Moreover, complications are minimal.This finding further confirms the significance of mechanical lithotripsy in the treatment of patients with difficult bile duct stones.
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The paper presents clinical observation of a patient with cholelithiasis and so-called “difficult” choledocholithiasis. Considering the developed complications – mechanical jaundice and purulent cholangitis, as well as large operative risk, it was decided to refrain from open surgical intervention. Traditionally-performed endoscopic stone extraction did not provide any success. Contact electro-impulse lithotripsy and lithotomy were performed. This enabled choledocholithiasis and cholangitis to be eliminated, bile ducts patency to be restored, and ensured the possibility of safe elective surgical intervention for chronic calculous cholecystitis.
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【Objective】To compare the efficacy and advantage of the improved flank position with coventional lithotomy position in holmium laser lithotripsy through ureteroscope for upper ureteral calculi.(【Methods】)One hundred and fifty cases were randomly assigned to the group A with the improved flank position,meanwhile 75 cases were randomly assigned to the group B with the conventional lithotomy position.All patients underwent transureteroscope lithotripsy for upper ureteral calculi.The successful rate of stone fragmentation after single procedure was compared between two groups.【Results】The successful rate of stone fragmeatation with single procedure was 96% in group A,obviously higher than 64% in group B(P0.05).【Conclusion】The improved flank position is appropriate and effective for holmium laser lithotripsy through ureteroscope for upper ureteral calculi.It has more advantages than conventional lithotomy position.Its successful rate is similar to that of ESWL and flexible ureteroscope lithotripsy for upper ureteral calculi according to reports of the same period.therefore it can be considered as the first choice for treating upper ureteral calculi through ureteroscope.
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After the development of EST, various kinds of Lithotripsy has been used for fragmentation of large bile duct stones that can't be extracted by Basket catheter. Several centers have reported success in bile stone fragmentation and removal via percutaneously or via transpapillary by using various techniques. (mechanical stone extraction, ultrasonic lithotripsy, electrohydraulic lithotripsy, Nd: YAG laser) Some reports suggested that there was possibility of bile duct damage by using EHL or Nd:YAG laser.In our hospital, almost of CBD stone was extracted by using Basket catheter or MHL. But 3% of cases has been adapted to EHL.(guided by PTCS or PCPS) In this report, five cases with large bile duct stones were treated successfully with pulsed-dye laser.(Two cases were guided by PCPS, three cases were guided by PTCS.) Lithotripsy was performed under direct vision with choledochoscopes, and there were no significant complications.Pulsed-dye laser is thought to effect fragmentation by laser light absorption onto the stone surface. The light may initiate a plasma on the stone surface that can rapidly expand and collapse, initiating a mechanical shock wave that has less bile duct injury. Pulsed-dye laser seems to be safe and effective in endoscopically directed lithotripsy of large bile duct stones.
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Objective To summarize the value of Holmium laser lithotripsy applied to removal of stones from the bile duct under cholangioscopy. Methods In our hospital from October 2012 to May 2013, 26 cases of patients with bile duct stone treated by holmium laser were studied. Results The operation was successful, and the bile duct stones were all removed, the average time of taking stone was 25 min, and there was no complication after operation.Conclusions Holmium laser lithotripsy applied to removal of stones from the bile duct under cholangioscopy has the advantage of convenient operation,short time consumption, and easy to take all of the bile duct stones at a time.It has apparent advantage in removal of diameter larger than 1 centimeter biliary stones,which incarcerated into distal common bile duct.
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Objective: The aim of this study was to evaluate the feasibility and efficacy of choledochoscopic holmium laser lithotripsy as a means of removing resistant extrahepatic and intrahepatic bile duct stones. Methods: Clinical data on 28 patients who had undergone choledochoscopic holmium laser lithotripsy were analyzed. Results: Complete stone clearance was obtained in 24 patients; small numbers of residual stones in the left or right hepatic duct were found in 4 patients. No severe complications such as hemobilia and bile duct injuries occurred. Conclusion: Choledochoscopic holmium laser lithotripsy is a simple, safe, and effective treatment method for patients with resistant bile duct stones.
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case, the applications of the instrument did not ever exceed two or three minutes' duration.
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Endoscopic retrograde laser lithotripsy of common bile duct stones is a new technique which can be carried out through the endoscope without anaesthesia using ordinary endoscopic equipment. In the method described here a flashlamp pulsed Neodymium YAG laser (wave length 1064mm) was used. Light energy was transmitted along a highly flexible quartz fibre with a diameter of 0.2mm. This new technique was used in nine patients with concrements in the common bile duct, which could not be removed with the established endoscopic techniques. In eight of the nine the concrements (maximum diameter 4.7 × 3.1 cm) could be fragmented and in six the fragments could be extracted from the common bile duct. The total energy required was 80-300J; complications were not observed.
Laser lithotripsy
Endoscope
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