Extracorporeal shock-wave lithotripsy and the management of common bile-duct calculi

ESWL experience in the therapy of difficult bile duct stones

In recent years, alternatives to surgery for difficult bile duct stones have been developed. Routine endoscopy fails in about 10% of patients. To verify the role of extracorporeal shock wave lithotripsy in residual CBD stones, we treated 32 patients by HM4 or MPL 9000 Dornier lithotripters. Ten (34.4%) patients needed two extracorporeal shock wave lithotripsy sessions, and 3 (10.3%) patients three. Complete clearance was achieved in 29 patients (90.6%) after one or more sessions either by endoscopic (20 pts) or percutaneous (9 pts) extraction of the debris; of the remaining 3 patients, in 2 a bilioduodenal stent was placed and in 1 electrohydraulic lithotripsy was performed. Eighteen and seven-tenths percent transient mild hemobilia, 12.5% microhematuria, and no mortality were observed. It is possible to state that in site- or size-related difficult biliary stones, extracorporeal shock wave lithotripsy is a rapid, safe, and highly effective treatment as an additional nonoperative option to resolve the failure of routine endoscopic measures.

Extracorporeal shock wave lithotripsy for bile duct stones: an Australian experience

Choledocholithiasis requires prompt therapy, particularly if complicated by ascending cholangitis. Endoscopic sphincterotomy with balloon and basket extraction clears the bile duct in 90% of patients. Failure is usually associated with large stones, that is, greater than 2 cm. Until recently such patients would have required surgical intervention. In 1986 St Vincent's Hospital installed a Dornier HM3 Lithotriptor to be used for both urinary tract and bile duct calculi. A retrospective analysis of patients referred for extracorporeal shock wave lithotripsy (ESWL) to bile duct stones was performed. There were 47 patients (28 female, 19 male) with an average age of 76 years. Twenty-two patients had a single stone with a mean diameter of 2.4 cm and 25 had multiple stones. In two patients the stone was not able to be visualized, so ESWL could not be performed. Complete stone clearance was achieved without further intervention in 13 patients, and in a further 23 after endoscopic extraction of fragments. In five patients only partial duct clearance was achieved. However, this provided palliation and enabled the patient to be discharged. Surgical intervention was required in the remaining four cases. Overall success rate was 80% with a further 11% being palliated with improved biliary drainage. There were no serious adverse effects from ESWL. All patients were discharged from hospital. Mortality at 30 days was 4.7% and at 6 months was 19.4%. One patient succumbed to ascending cholangitis 22 weeks post-ESWL (2.7%). All other deaths were unrelated to ESWL or biliary disease. We conclude that ESWL is a safe and effective treatment for bile duct stones not amenable to endoscopic extraction.

Extracorporeal shock-wave lithotripsy of bile duct calculi. An interim report of the Dornier U.S. Bile Duct Lithotripsy Prospective Study

A multi-institutional study to evaluate the efficacy, clinical application, and safety of extracorporeal shock-wave lithotripsy (ESWL) with the Dornier HM-3 or HM-4 lithotripter for bile duct calculi (BDC) was initiated in September, 1987. Symptomatic patients who entered into this prospective trial had BDC in the common bile duct and/or the intrahepatic, cystic or lobar ducts of the liver that were inaccessible or untreatable by papillotomy or percutaneous stone extraction. The study excluded gallbladder stones. Nasobiliary (54.4%) or transhepatic catheters (10.5%) and T-tube or cholecystostomy tubes (17.5%) or combinations (14.0%) permitted access for radiographic contrast to allow fluoroscopic monitoring of stone position and fragmentation. Exclusion criteria included pregnancy, failure to localize the stone, disturbances of coagulation, pacemakers, or vascular aneurysms or large bones that lie in the focal axis of the shock waves. Eleven institutions treated 42 patients (23 male, 19 female) with BDC; age range was 25 to 95 years (mean +/- SD, 73.5 +/- 13.8) and ASA risk category was 1 to 4 (mean, 2.3 +/- 0.8). Fourteen patients (33.3%) had a single BDC; 28 had 2 to 8 stones (mean, 2.7 +/- 1.8) ranging in size from 6 mm to 30 mm (mean, 18.5 +/- 6.4). The majority (66.7%) of patients were postcholecystectomy. The 42 patients received 57 ESWL treatments consisting of 600 to 2400 shocks per treatment (mean, 1924 +/- 289) at 12 to 22 kV (mean, 18.5 +/- 1.9) administered over 20 to 125 minutes (mean, 52.9 +/- 20.8). General anesthesia was used in 32% of the treatments; the majority were treated with epidural or regional block (42.1%), local infiltration (28.1%), or intravenous sedation (38.6%). Fifteen patients (35.7%) required two ESWL treatments. Stone fragmentation occurred in 94.6% of evaluable patients and in 90.4% of ESWL treatments, respectively; however, BDC fragments remained in 59.5% of patients 24 hours after treatment (diameter less than or to 3 mm, 12%; 4 to 9 mm, 16%; greater than or equal to 10 mm, 68%). Some patients (50%) required adjunctive procedures to achieve stone removal that included endoscopic extraction (n = 10; 47.6%), biliary lavage (n = 8; 38.1%), endoscopic bile duct prosthesis (n = 1; 4.8%), and operation (n = 2; 9.5%). ESWL treatment complications during hospitalization were observed in 15 patients (35.7%) and were present in four (9.5%) at discharge. Complications included macrohematuria (5%), biliary pain (15%), biliary sepsis (5%), hemobilia (10%), ileus (2.5%), and adverse pulmonary changes (7.5%). One patient developed pancreatitis before ESWL at ERCP that resolved prior to discharge.(ABSTRACT TRUNCATED AT 400 WORDS)