Tu1536 Single-Operator Cholangioscopy Is More Cost-Effective Than Bile Duct Exploration for Management of Difficult Common Bile Duct Stones After Failed Conventional ERCP
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Laser lithotripsy
Balloon catheter
Balloon dilation
The use of laser lithotripsy with an integrated stone-tissue discrimination system is an ambitious treatment modality for bile duct stone fragmentation. The aim of our prospective study was to determine the effectiveness and safety of the laser system and to find whether it reduced the need for choledochoscopy.Thirty patients with complicated bile duct stones were treated perorally with a flashlamp-pulsed Rhodamine-6G dye laser and an automatic stone-tissue discrimination system. Initial treatment sessions were performed under fluoroscopic guidance in each patient and switched to choledochoscopic control if the stone could not be approached properly.Eighteen of 19 patients with extrahepatic bile stones were treated under fluoroscopic control; 17 of 19 patients were successfully treated through laser therapy. In nine of the patients with intrahepatic stones (n = 11), choledochoscopy was necessary for sufficient laser lithotripsy; seven of those patients became stone-free. Twenty-four of 30 patients (80%) were stone-free after sole laser therapy. Combined with other methods, the overall success rate was 27/30 (90%). Therapy-related mortality was 0%.Laser lithotripsy is effective and safe. The stone-tissue discrimination system facilitates therapy under fluoroscopic control and precludes the need for choledochoscopy, which is highly significant (p <0.001) if the calculi are extrahepatically located.
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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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Objective To evaluate the therapeutic efficacy and safety of endoscopic sphincterotomy （EST） combined with large balloon dilation for bile duct stones. Methods A total of 83 patients with com- mon bile duct stones were randomly divided into 2 groups to receive standard EST （n = 41, EST group） or EST plus large balloon dilation （ n = 42, EPLBD group） , respectively. The number of endoscopic session, operation time, rates of successful complete stone retrieval, mechanical lithotripsy, and procedure related complication were compared between the two groups. Results The rate of early procedure-related complica- tions was similar in 2 groups （9/41 vs. 7/42, P 〉 0. 05 ）, including perforation （ 1/41 vs. 0/42, P 〉 0. 05 ）, bleeding （5/41 vs. 2/42, P 〉0. 05） and pancreatitis （3/41 vs. 5/42, P 〉0. 05）. The rate of suc- cessful complete stone removal was also similar in 2 groups （39/41 vs. 41/42, P 〉 0. 05）. However, EST group needed more procedure time （38. 8 ± 4. 3 min vs. 29.2 ± 5.3 rain, P 〈 0. 01 ） and use of mechanical lithotripsy to achieve complete stone removal （9/41 vs. 2/42, P 〈 0. 05 ）. Only one patient in EPLBD group （ 1/42, 2.4% ） needed a second ERCP to clear bile duct stone, while in EST group, 8 patients underwent a second procedure （ 19. 5% , P 〈 0. 05）. Conclusion For endoscopic removal of common bile duct stones, EST combined with large balloon dilation is as safe and effective as EST, while easier in manipulation.
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Common bile duct calculi; Sphincterotomy; Endoscopic; Balloon dilatation
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AIM:To study the efficacy and the safety of laser lithotripsy without direct visual control by using a balloon catheter in patients with bile duct stones that could not be extracted by standard technique. METHODS:The seventeen patients (7 male and 10 female; mean age 67.8 years) with difficult common bile duct (CBD) stones were not amenable for conventional endoscopic maneuvers such as sphincterotomy and mechanical lithotripsy were included in this study.Laser wavelengths of 532 nm and 1064 nm as a double pulse were applied with pulse energy of 120 mJ.The laser fiber was advanced under fluoroscopic control through the ERCP balloon catheter.Laser lithotripsy was continued until the fragment size seemed to be less than 10 mm.Endoscopic extraction of the stones and fragments was performed with the use of the Dormia basket and balloon catheter. RESULTS:Bile duct clearance was achieved in 15 of 17 patients (88%).The mean number of treatment sessions was 1.7 ± 0.6.Endoscopic stone removal could not be achieved in 2 patients (7%).Adverse effects were noted in three patients (hemobilia, pancreatitis, and cholangitis). CONCLUSION:The Frequency Doubled Double Pulse Nd:YAG (FREDDY) laser may be an effective and safe technique in treatment of difficult bile duct stones.
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Endoscopic sphincterotomy followed by extraction using a Dormia basket or an extraction balloon catheter is the procedure that is generally used for the removal of bile duct stones. This is not successful in all patients, however, and some stones have to be extracted using lithotripsy devices. In an attempt to avoid mechanical lithotripsy, we used large-diameter balloons after sphincterotomy for removing stones that could not be extracted using the conventional methods.In this retrospective pilot study, large-diameter (15-mm, 18-mm, or 20-mm maximum sizes) balloon dilation of the sphincterotomy site was performed in 50 patients in whom bile duct stones could not be removed by endoscopic sphincterotomy and Dormia basket or balloon catheter extraction.The stones varied in size from < 15 mm to 25 mm. Common bile duct stones could be removed in all the patients using the large-diameter balloon technique. A Dormia basket or an extraction balloon catheter was required for removal of stones in 29 patients (58 %); and mechanical lithotripsy was required in five patients (10 %). Minor oozing of blood was seen in 16 patients (32 %), but the ooze stopped spontaneously during the endoscopy. Melena occurred in two patients and major bleeding requiring surgery occurred in one patient. Mild acute pancreatitis that resolved with conservative management occurred in four patients (8 %). There were no perforations and no deaths.Large-diameter balloon dilation of the sphincterotomy site is an effective procedure for removal of bile duct stones that cannot be extracted by endoscopic sphincterotomy and conventional extraction devices. Mechanical lithotripsy could be avoided in the majority of these patients using this approach.
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Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard procedure for the treatment of bile duct stones, and most stones are successfully removed with accessories such as biliary baskets or extraction balloons. Impaction of a biliary basket is not an uncommon complication of this procedure, being reported in 0.8 % – 5.9 % of cases. Mechanical lithotripsy usually solves the problem by crushing the stone, followed by extraction of the stone fragments. However, on rare occasions, fracture of the basket occurs during mechanical lithotripsy, and this can pose a special management problem, depending on where the breakage occurs [1] [2] [3]. We report the successful management of an impacted biliary basket after breakage of the basket handle cord during extra-endoscopic mechanical lithotripsy.
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Ninety percent of patients with intraductal biliary stones are successfully treated with sphincterotomy and subsequent stone extraction. However, technical difficulty increases with stone size and giant stones require fragmentation to facilitate endoscopic removal. For stones too large to be engaged in a basket for mechanical lithotripsy, laser and electrohydraulic lithotripsy have been proposed for stone fragmentation. Application of electrohydraulic lithotripsy (EHL) is best achieved under direct visualization during cholangioscopy, because shock waves can also injure normal tissue. We present the case of a patient who underwent direct cholangioscopy for EHL of a giant stone that could not be retrieved by endoscopic retrograde cholangiopancreatography (ERCP). This article is part of an expert video encyclopedia.
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