Endoscopic laser lithotripsy for complicated bile duct stones: is cholangioscopic guidance necessary?

Abstract

-Background -Endoscopic papillotomy is successful in more than 95% of the cases of choledocholithiasis. For patients with difficult bile duct stones not responding to mechanical lithotripsy, different methods for stone fragmentation have been developed. Aims -To compare the results of laser lithotripsy with a stone-tissue recognizing system, when guided by fluoroscopy only or by cholangioscopy. Methods -Between 1992 and 2002 we have treated 89 patients with difficult bile duct stones by endoscopic retrograde cholangiopancreatography endoscopic retrograde cholangiopancreatography and laser lithotripsy. Unsuccessful e�tracorporeal shoc�-wave lithotripsy and electrohydraulic were also performed before laser in �5% e�tracorporeal shoc�-wave lithotripsy and electrohydraulic were also performed before laser in �5% and electrohydraulic were also performed before laser in �5% electrohydraulic were also performed before laser in �5% were also performed before laser in �5% and 26% of the cases, respectively. Results -Laser was effective in 79.2% of 72 patients guided by cholangioscopy and in 82.4% of 17 cases steered by fluoroscopy. The median number of impulses in the latter was 4,��5 and 1,800 with the former technique. Two parameters influenced the manner of laser guidance. In cases of stones situated above a stricture, cholangioscopic control was more effective (64.7% vs. �1.9%). When the stones were in the distal bile duct, fluoroscopic control was more successful. Conclusion -In cases of difficult stones in the distal bile duct, laser lithotripsy under fluoroscopic control is very effective and easily performed. Cholangioscopic guidance should be recommended just in cases of intrahepatic stones or in patients with stones situated pro�imal to a bile duct stenosis. In these cases, cholangioscopy should be performed either endoscopically or percutaneously.

Cholangioscopy and pancreatoscopy (with videos)

“…D-F, A large common bile duct stone in a grossly dilated common bile duct that was fragmented under direct visualization by using electrohydraulic lithotriopsy (Olympus pediatric gastroscope shockwave pulses to the bile duct wall that can lead to bleeding and perforation. [72][73][74][75] The success rate of cholangioscopically guided lithotripsy for complicated choledocholithiasis is high, varying from 85% to 97%. 25,[74][75][76][77][78][79] In most cases, stone disintegration and complete bile duct clearance can be achieved within a single treatment session.…”

Intraductal therapies

“…The direct visualization helps in preventing injury from an EHL probe compared to positioning the EHL probe under fluoroscopy. Success rate of cholangioscopically directed CBD stone removal by these method ranges from 71 to 100% [49,50].…”

“…The holmium:YAG laser and frequency-doubled, double-pulse neodymium:YAG (FREDDY) laser are the two commonly used lasers to crush biliary stones [49,50,52]. In holmium laser technology (Medilas H20; Dornier Medtech, Munich, Germany) the energy is delivered via a 365-µm-diameter fiber, with energy levels set at 800-1500 mJ at a frequency of 8-15 Hz.…”

Per-oral cholangioscopy

“…Various studies have reported high success rates ranging from 80% to 100% in clearing the bile ducts of stones after cholangioscopic EHL or LL. [54][55][56] In a study by Neuhaus et al, comparing the efficacy of ESWL and cholangioscopy guided LL, the latter was found to be more effective in clearing bile duct stones (73% vs. 97%). 57 After a cross-over to the LL arm, biliary clearance was achieved in seven out of eight patients who failed ESWL.…”