Radiol Oncol 1994; 28: 174-7.
Extracorporeal shock - wave lithotripsy in the management of
bile duct stones
Alojz Pleskovic1 and Franc Jelenc2
'Medical Faculty, Ljubljana, 2Clinical Centre, Ljubljana, Slovenia
Extracorporeal shock - wave lithotripsy (ESWL) was undertaken in 16 patients with extra or intrahepatic bile duct stones which could not be removed endoscopically. Stone fragmentation was successful in 14 patients with stones in the biliary tract. Fragmentation failed in two patients with stones impacted in the pappila Vateri and had to be removed surgicaly. 14 of the 16 patients were free of stones after spontaneous passage (n = 9) or after endoscopic removal of the residual concrements (n = 5). Complications occurred in only three patients after ESWL (transitory hemobi-lia, transient hematuria). These data point to ESWL being clearly preferable to surgical intervention in bile duct stones refractory to endoscopic treatment, especially in the elderly with an increased perioperative risk.
Key words: cholelithiasis; lithotripsy
Introduction
The article by Sauerbuch et al. (1986), in which the autors describe their experience in Germany with the fragmentation of gallstones by means of extracorporeal shock waves (ESWL), generated a great deal of interest ali over the world.'-7 In our institution, most residual or primary bile duct stones after cholecystectomy are treated with basket extraction through an endoscopic spincterotomy. These technique may fail if the stones are large (> 2 cm) or if they are in an unfavorable location (e. g., in an intrahepatic duct or beyond a stricture). The endoscopic approach may be impossible when the normal anatomic relationship between the bile duct
Corespondence to: Alojz Pleskovic MD, Medical Faculty, Korytkova 4, 61105 Ljubljana, Slovenia.
UDC: 616.366-003.217.7-089.879
and the duodenum is altered (e. g., periampullary diverticulum) or when the sphincter can not be reached because of previous gastrointestinal surgery.
Material and methods
Between October 1988 and March 1992 we used ESWL to treat 16 patients who had residual or primary bile duct stones after cholecy-stectomy. The patients were divided into two groups, 11 patients with residual bile duct stones and 5 patients with primary bile duct stones after cholecystectomy. In both groups, the indication for treatment was the failure of or anticipated difficulty with basket extraction of the stone. In five of these 16 patients, basket extraction via endoscopic sphincterotomy either had failed or had not been attempted because of the large size of stones (> 20 mm in three
Extracorporeal shock - wave lithotripsy in the management of bile duct stones
175
patients) or the presence of an anatomic anomaly (periampulary diverticulum in two patients). Eleven patients had a T - tube in the bile duct, but basket extraction via an endoscopic sphincterotomy was impossible because the stones were in an unfavorable location (e. g., in an intrahepatic duct in six patients) or because of the large size of the stones ( > 20 mm in three patients) or because of a previous gastrointestial surgery (partial gastrectomy with Roux - en y anastomosis in two patients).
Baseline blood studies, including lactic dehydrogenase (LDH), aspartate transferase (AST), serum amylase, prothrombin time and partial tromboplastin time, and urinalysis were done less than 48 hr before ESWL and were repeated within 24 hr after the treatment. Abnormal tests were repeated until they returned to normal. Bile drainage was tested for blood. Ali patients had a coagulogram the day after the
treatment and at least one more cholangiogram before discharged or treated further.
The study group included thirteen women and three men (age range, 27-84 years). Most of the patients were more than 6.5 years old. The treatments were performed by using Sie-mens-Lythrotripter equipment.
Results
All stones were fragmented successfully in 14 of the 16 patients. Fragmentation required one session in 12 patients, two sessions in one patient, four sessions in one patient. After ESWL, the stone fragments passed spontaneously in nine patients. In five patients the fragmented stones were removed by basket extraction through the endoscopic sphincterotomy. In two patients ESWL fragmentation failed and impacted stones in the pappila Vateri had to
Figure l. ERC showing a gallstone in the common bile duct.
.Figure 2. ERC after ESWL and spontaneous passage of fragments.
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Pleskovic A and Jeleni! F
be removed surgicaly. The patients remained in the hospital from 2 to 14 days after the procedure, depending mainly on whether additional intervention was required. No clinically significant adverse reactions could be observed; in particular no evidence of pancreatitis was present. In two patients, transitory hemobilia developed. One patient had transient hematuria. Short - term elevations of LDS and AST were observed in most of the patients. Bruising of the skin was seen in four patients, but none had significant pain (Figure 1--4).
Figure 3. ERC showing a huge gallstone in the common bile duct.
Figure 4. ERC after ESWL and extraction of fragments with Dorrnia basket.
Discussion
With the introduction of ESWL, another technique has become available for the nonsurgical management of bile duct stones.1 A prerequisite for using ESWL in the treatment of bile duct stones is the presence of a biliary drainage tube. This may be a T - tube or a nasobiliary tube. Such a tube is indispensable because unless the stones are calcified, they must be visualized by injection of contrast material. Ductal stones rarely can be localized sufficiently by sonography.
The optimal or maximal number of shock waves has not yet been definitely established. Sauerbuch et. al. found that 500 - 1500 shocks' were sufficient to fragment the stones. Other autors have reported the use of up to 3300 shocks.8,9 Our use of between 1500 and 3000
shocks is therefore within the range of present practice. Pancreatitis, which has been described in the treatment of gallbladder stones, has not been reported in patients in whom the treatment was performed for retained common bile duct stones, possibly because of the presence indwelling drainage tube.
The lack of clinically significant adverse reactions to ESWL in our patients is in accordance with the data reported in the literature. 10,11 However, the transient elevations of LDH and AST - indicating liver - cell damage - may be related to the higher - than average number of shock waves used. Our rate of successful fragmentation of stones (88 % ) is about the same as that reported in the literature, the rate of spontaneous passage of fragments (56 % ) is also about the same as that found in other centres.1215
Exlracorporeal .shock - wave lithotripsy in the management of bile duct .stone!:
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Conclusion
ESWL a is successful method for the management of patients with bile duct stones when used in conjunction with other nonsurgical teh-niques.
References
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