Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients.

Abstract

Percutaneous, transhepatic, intracorporeal, electrohydraulic shock wave lithotripsy was performed in 50 patients after failure of endoscopic treatment (n = 43) or directly in patients with a strictured hepaticojejunostomy (n = 7). Twenty-seven patients had common bile duct stones; 23, intrahepatic stones. Three steps were used: A transhepatic bilicutaneous fistula was created, a wide communication between the bile duct and the gut was established, and contact shock wave lithotripsy was performed under endoscopic guidance. Afterward, 46 patients were free of stones. In four patients with diffuse intrahepatic lithiasis, only 75% of stones could be cleared. Severe complications, seen in 11 patients (hemobilia necessitating transfusion [n = 6], bile duct perforation resulting in cholangitis [n = 3], acute pulmonary edema [n = 1], and hemothorax [n = 1]), were fatal in four patients; all occurred early in the study. The authors modified their technique by dilating the biliary tract in two sessions 3 days apart, waiting 6 days for the tract to mature, and then introducing the cholangioscope directly through the skin, significantly reducing complications and mortality (P less than .005).

Intrahepatic Stones: The Percutaneous Approach

“…These procedures can be performed under conscious sedation and analgesia. This gradual sinus tract technique is safer than dilation as a single step procedure (14). Cholangioscopy can be carried out as early as seven to eight days after the initial PTC procedure through the stabilized fibrous cutaneobiliary fistula (14,23,29).…”

“…This gradual sinus tract technique is safer than dilation as a single step procedure (14). Cholangioscopy can be carried out as early as seven to eight days after the initial PTC procedure through the stabilized fibrous cutaneobiliary fistula (14,23,29). Percutaneous stone removal: Stones should be extracted percutaneously only through sheaths unless the sinus tract was created three to four weeks before the procedure.…”

“…The frequency and the intensity of the shockwave generation can be adjusted depending on the size and composition of the stones. Although EHL probes with built-in balloon catheters for positioning in the central axis of the bile duct are available, cholangioscopic control of shockwave application is strongly recommended because damage of the ductal wall may occur when the ductal wall comes in direct contact with the probe (13)(14)(15)(16)(17)(18)(19)(20)(21). Laser lithotripsy: Several systems for biliary laser lithotripsy have recently been reported in animal and clinical studies.…”

“…Otherwise, disrupture of the fistula may occur. A safe, rapid and effective alternative is the prograde removal of concrements through the papilla or through a pre-existent biliodigestive anastomosis, preferrably after intracorporeal lithotripsy (14,23,29). For this purpose, a cholangioscope can be inserted into the biliary system through the mature cutaneotranshepatic fistula or the T tube tract under direct visual control without the need for guidewires or sheaths or overtubes.…”

“…After maturation of a cutaneobiliary fistula, cholangioscopic procedures rarely cause serious complications. Minor hemobilia was seen in up to 20% of patients treated with EHL but could be managed conservatively (14,15,19).…”