Multidisciplinary conservative treatment of difficult bile duct stones: a real alternative to surgery.

E Masci,M Castrucci,L Fanti,P A Testoni,S Spagnolo,A Mariani,A Tittobello,W Zuliani

doi:10.1155/1997/42087

Abstract

56 patients with large CBD or intrahepatic stones underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock wave lithotripsy. Percutaneous access to the biliary tract was chosen when an endoscopic approach was not possible (hepaticojejunostomy in 5 patients, 1 juxtapapillary diverticulum and I inflammatory bile duct stricture). Visualization of stones was achieved radiologically in 32 patients and by ultrasound in 24. The procedure was successful in 47 of 56 treated patients (83.9%). Clearance of the biliary tract was obtained in 25 cases (53%), whereas in 22 cases (47%) complete clearing of biliary tract was obtained only after endoscopic extraction of fragments (17 cases) or percutaneous (5 cases). The median number of shock waves in each session was 1725 (range 300–3166), which were applied during one (n=30), two (n=22) or three sessions (n=4). The only complications were 1 case of symptomatic hyperamylasemia and 3 cases of macrohematuria. In conclusion, extracorporeal lithotripsy combined with endoscopic and/or percutaneous treatment is a real alternative to surgery for difficult stones.

Highlights

The treatment of common bile duct (CBD) stones as well as both multiple and complex intrahepatic lithiasis, is no longer exclusively surgical
From 1989 to 1994, 56 patients, 30 men and women, aged from to 92 years, underwent endoscopic and/or percutaneous treatment followed by extracorporeal shock-wave lithotripsy the choice of non-surgical treatment was based on the old age of patients, on higher surgical risks factors and, for younger patients, because of previous multiple surgical intervention. 44 patients were treated because of evidence for large CBD stones not amenable to routine endoscopic measures (Dormia Basket and mechanical lithotripsy). 12 patients had intrahepatic lithiasis, 3 of them with associated CBD stones
For 7 patients, percutaneous access to the biliary tract was chosen because endoscopic access was not possible for anatomical reasons or by conditions that might limit endoscopic sphincterotomy (1 juxtapapillary diverticulum, 1 inflammatory bile duct stricture) in these cases the maximum stone size per patient ranged from 6.5 to 10 mm

Summary

Introduction

The treatment of common bile duct (CBD) stones as well as both multiple and complex intrahepatic lithiasis, is no longer exclusively surgical. Both endoscopic and transhepatic percutaneous approaches, sometimes combined, may offer successful treatment for most cases [1,2,3]. When very large stones have to be managed or anatomic conditions interfere with their removal, the success rates of nonsurgical methods are much lower [4]. Extracorporal lithotripsy has been demonstrated to be useful for treatment of large stones in the CBD and biliary intrahepatic ducts.

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Results

Conclusion