How Should Biliary Stones be Managed?

Abstract

Minimally invasive therapy is currently invaluable for the treatment of biliary stones. Clinicians should be familiar with the various endoscopic modalities that have been evolving. I reviewed the treatment of biliary stones from the common practice to pioneering procedures, and here I also briefly summarize the results of many related studies. Lithotripsy involves procedures that fragment large stones, and they can be roughly classified into two groups: intracorporeal modalities and extracorporeal shock-wave lithotripsy (ESWL). Intracorporeal modalities are further divided into mechanical lithotripsy (ML), electrohydraulic lithotripsy, and laser lithotripsy. ESWL can break stones by focusing high-pressure shock-wave energy at a designated target point. Balloon dilation after minimal endoscopic sphincterotomy (EST) is effective for retrieving large biliary stones without the use of ML. Peroral cholangioscopy provides direct visualization of the bile duct and permits diagnostic procedures or therapeutic interventions. Biliary stenting below an impacted stone is sometimes worth considering as an alternative treatment in elderly patients. This article focuses on specialized issues such as lithotripsy rather than simple EST with stone removal in order to provide important information on state-of-the-art procedures. (Gut Liver 2010;4:161-172

Efficacy and safety of sphincterotomy with sphincteroplasty using large caliber balloons in the treatment of choledocholithiasis with extraction difficulties

“…Although a priori removal of the stones proved more difficult in the ES with SP group, the success rate was similar in both cases (94% in the ES with SP group versus 97% in the ES group) and consistent with the findings of other studies [13,14,16,17,19,21,22]. Likewise, no differences were observed between the two groups in terms of complications.…”

“…In our series, the global mortality rate was 3.28%, and was only slightly higher in the ES with SP group (3.8%) than in the ES group (2.7%)-with no significant differences between them. Our complication rate was somewhat lower than in other studies [13,14,16,17,22]. The incidence of acute pancreatitis was practically identical in both groups (1.9% in the ES with SP group versus 2% in the ES group), and in no case did we use pancreatic stents.…”

“…There is no consensus in the literature on the extent of previous ES, dilatation time, or maximum balloon size. Shim et al recommend a small ES in order to lessen the risk of perforation [14], while in contrast Attam and Mayedeo recommend that ES should be as extensive as possible [11,16]. We are more in agreement with this latter position, and do not modify the extent of ES according to whether dilatation will be carried out or not.…”

“…In addition, they are less effective in application to large or impacted stones, and have a relatively high complication rate [5,9,10]. More sophisti-cated intraductal lithotripsy techniques such as electrohydraulic or laser lithotripsy, etc., for the fragmentation of large stones, are expensive and available in very few centers [11][12][13][14]. The placement of plastic biliary stents may offer a temporary solution prior to surgical removal, or may represent a definitive treatment option in very elderly patients or individuals with a very high surgical risk [14,15].…”

“…More sophisti-cated intraductal lithotripsy techniques such as electrohydraulic or laser lithotripsy, etc., for the fragmentation of large stones, are expensive and available in very few centers [11][12][13][14]. The placement of plastic biliary stents may offer a temporary solution prior to surgical removal, or may represent a definitive treatment option in very elderly patients or individuals with a very high surgical risk [14,15]. When we use this technique and have already performed ES, we usually place more than one plastic stent in order to ensure improved drainage, and also to avoid displacements.…”