Cholangioscopy (CP) with Electrohydraulic Lithotripsy (EHL) in Patients (PTS) with Difficult Bile Duct Stones

Abstract

Background: Large, adherent, and intrahepatic stones may be refractory to conventional stone extraction methods. The aim of this study was to determine 1) the efficacy of CP +/− EHL for stones and 2) pt characteristics associated with stone recurrence. Methods: Prospective cohort of consecutive pts referred for CP to treat difficult bile duct stones. A data collection sheet was used to obtain: pt/stone characteristics; prior ERCP/PTC; CP interventions; stone recurrence. Follow-up was by chart review/phone. Results: Between 2/00 and 10/04, 44 pts (27M/17F; mean age 63 yrs, 9 with PSC) had 69 CPs (64 transpapillary, 5 percutaneous) for management of difficult stones or evaluation of associated strictures. A mean of 2.8 (range 1-13) ERCP/PTCs were performed prior to index CP. Stone location: intrahepatics (N=11); extrahepatics (N=23); both (N=10). Stone type: pigmented (N=12); cholesterol (N=8); mixed (N=15); unknown (N=9). Mean stone size was 13 mm (range 4-27). 11/44 (25%) pts had downstream strictures. 10/44 (23%) pts had stones detected by CP only and missed by cholangiography. 11/39 (28%) pts had extension of a previous biliary sphincterotomy. 35/44 (80%) pts had CP-directed lithotripsy: 33 EHL; 2 mechanical. 6/44 (14%) had balloon/basket sweep following CP visualization of stones. 3/44 (7%) had CP immediately following conventional methods of stone extraction to confirm stone clearance. From time of referral, pts required a mean of 1.7 (range 1-3) CPs +/− ERCPs to achieve complete (N=32), partial (N=10), or failed (N=2) stone clearance. 26/32 (81%) pts with complete clearance required a mean of 1.4 (range 1-3) CP-directed lithotripsy sessions. Failed cases were due to prior biliary bypass limiting access of CP to intrahepatic stones and early termination of CP due to inadequate sedation. Follow-up was obtained in 38/44 (86%) pts for a mean of 20.7 months. In pts with complete clearance, stones recurred in 6/32 (19%) requiring a mean 2.3 (range 1-5) subsequent biliary procedures; 5/6 had associated strictures or intrahepatic stones. Surgery: partial hepatectomy (N=1) and biliary bypass (N=2). Complications: 1 mild cholangitis. Conclusions: 1) CP-directed lithotripsy is safe and achieves stone clearance in most patients referred for difficult bile duct stones. 2) Following stone clearance, most pts with recurrence had intrahepatic stones or associated biliary strictures. 3) Nearly one in four pts had stones seen on CP that were missed by cholangiography. Background: Large, adherent, and intrahepatic stones may be refractory to conventional stone extraction methods. The aim of this study was to determine 1) the efficacy of CP +/− EHL for stones and 2) pt characteristics associated with stone recurrence. Methods: Prospective cohort of consecutive pts referred for CP to treat difficult bile duct stones. A data collection sheet was used to obtain: pt/stone characteristics; prior ERCP/PTC; CP interventions; stone recurrence. Follow-up was by chart review/phone. Results: Between 2/00 and 10/04, 44 pts (27M/17F; mean age 63 yrs, 9 with PSC) had 69 CPs (64 transpapillary, 5 percutaneous) for management of difficult stones or evaluation of associated strictures. A mean of 2.8 (range 1-13) ERCP/PTCs were performed prior to index CP. Stone location: intrahepatics (N=11); extrahepatics (N=23); both (N=10). Stone type: pigmented (N=12); cholesterol (N=8); mixed (N=15); unknown (N=9). Mean stone size was 13 mm (range 4-27). 11/44 (25%) pts had downstream strictures. 10/44 (23%) pts had stones detected by CP only and missed by cholangiography. 11/39 (28%) pts had extension of a previous biliary sphincterotomy. 35/44 (80%) pts had CP-directed lithotripsy: 33 EHL; 2 mechanical. 6/44 (14%) had balloon/basket sweep following CP visualization of stones. 3/44 (7%) had CP immediately following conventional methods of stone extraction to confirm stone clearance. From time of referral, pts required a mean of 1.7 (range 1-3) CPs +/− ERCPs to achieve complete (N=32), partial (N=10), or failed (N=2) stone clearance. 26/32 (81%) pts with complete clearance required a mean of 1.4 (range 1-3) CP-directed lithotripsy sessions. Failed cases were due to prior biliary bypass limiting access of CP to intrahepatic stones and early termination of CP due to inadequate sedation. Follow-up was obtained in 38/44 (86%) pts for a mean of 20.7 months. In pts with complete clearance, stones recurred in 6/32 (19%) requiring a mean 2.3 (range 1-5) subsequent biliary procedures; 5/6 had associated strictures or intrahepatic stones. Surgery: partial hepatectomy (N=1) and biliary bypass (N=2). Complications: 1 mild cholangitis. Conclusions: 1) CP-directed lithotripsy is safe and achieves stone clearance in most patients referred for difficult bile duct stones. 2) Following stone clearance, most pts with recurrence had intrahepatic stones or associated biliary strictures. 3) Nearly one in four pts had stones seen on CP that were missed by cholangiography.