Jelenc, Franc

Pleskovič, Alojz

English

Digital repository of Slovenian research organizations

Radio/ Oncol 1994; 28: 174-7. Extracorporeal shock - wave lithotripsy in the management of bile duet stones Alojz Pleskovič1 and Franc Jelenc2 1 Me_dical Faculty, Ljubljana, 2Clinical Centre, Ljubljana, Slovenia Extraeorporeal shoek - wave lithotripsy (ESWL) was undertaken in 16 patients with extra or intrahepatie bile duet stones whieh eould not be removed endoseopieally. Stone fragmentation was sueeessful in Z 4 patients with stones in the biliary traet. Fragmentation failed in two patients with stones impaeted in the pappila Vateri and had to be removed surgiealy. 14 of the 16 patients were free of stones after spontaneous passage (n = 9) or after endoseopie removal of the residual eoncrements (n = 5). Complieations oeeurred in only three patients after ESWL (transitory hemobi­lia, transient hematuria). These data point to ESWL being clearly preferable to surgieal intervention in bile duet stones refraetory to endoseopie treatment, espeeially in the elderly with an inereased perioperative risk. Key words: cholelithiasis; lithotripsy Introduction The article by Sauerbuch et al. (1986), in which the autors describe their experience in Gerrnany with the fragmentation of gallstones by means of extracorporeal shock waves (ESWL), genera­ted a great deal of interest ali over the world. 1-7In our institution, most residual or primary bile duet 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 duet or beyond a stricture). The endoscopic approach may be impossible when the normal anatomic relationship between the bile duet Corespondence to: Alojz Pleskovič MD, Medica! 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 duet stones after cholecy­stectomy. The patients were divided into two groups, 11 patients with residual bile duet sto­nes and 5 patients with primary bile duet 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 oj' bile duet stones 175 patients) or the presenee of an anato111ie ano-111aly (periampulary divertieulum in two pa­tients). Eleven patients had a T - tube in the bile duet, but basket extraetion via an endoseo­pie sphineterotomy was i111possible beeause the stones were in an unfavorable loeation (e. g., in an intrahepatie duet in six patients) or be­eause of the large size of the stones ( > 20 111111 in three patients) or beeause of a previous gastrointestial surgery (partial gastreetomy with Roux - en y anastomosis in two patients). Baseline blood studies, including laetie dehy­drogenase (LDH), aspartate transferase (AST), serum a111ylase, prothrombin tirne and partial tromboplastin tirne, 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 eoagulogram the day after the Figure l. ERC showing a gallstone in the common bile duet. treatment and at least one more eholangiogram before diseharged or treated further. The study group included thirteen wo111en and three men (age range, 27-84 years). Most of the patients were more than 65 years old. The treatments were peiionned by using Sie­mens-Lythrotripter equipment. Results All stones were frag111ented suceessfully 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 extrae­tion through the endoseopie sphineteroto111y. In two patients ESWL frag111entation failed and i111pacted stones in the pappila Vateri had to ,Figure 2. ERC after ESWL and spontancous passagc of fragments. 176 Pleskovič 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 e!evations 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 duet. Discussion With the introduction of ESWL, another techni­que has become available for the nonsurgical management of bile duet stones. 1 A prerequisite for using ESWL in the treatment of bile duet 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. Dueta! 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 Figure 4. ERC after ESWL and extraction of frag­ments with Dorrnia basket. 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 pedormed for retained common bile duet 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. JO,ll However, the transient elevations of LDH and AST - indicating !iver - celi damage - may be related to the higher - tirno averagenumber of shock waves used. Our rate ofsuccessful fragmentation of stones (88 % ) isabout the same as that reported in the literatu­re, the rate of spontaneous passage of fragments(56 % ) is also about the same as that found inother centres. 12·15 Exlraco,poreal shock - wave li1hotripsy in the management of bile duet stones 177 Conclusion ESWL a is successful method for the manage­ment of patients with bile duet stones when used in conjunction with other nonsurgical teh­niques. References l. Sauerbrueh T, Delins M, Paumgartner G, et. al. Fragmentation of gallstones by extraeorporeal shoek waves. N Engl .I Med 1986; 314: 818-22. 2. Mulley AG. Shoek - wave lithotripsy: assessing aslam - hang teehnology. N Engl .I Med 1986; 314:845-7.3. Ferrueei JT. Biliary lithotripsy: what will the issues be? A .1 R 1987; 149: 227-31.4. Burthenne HJ. The promise of extraeorporealshoek - wave lithotripsy for the treatment ofgallstones. A J R 1987; 149: 233-5.5. Raskin JB. The eontinuing direet assault on the gallstone: enlightening, eleetrifying, and shoeking.Gastrointest Endosc 1987; 33: 262-3.6. Nahrwold DL. Fragmentation of biliary traet sto­nes by lithotripsy using local anesthesia. ArchSurg 1988; 123: 91-3.7. Van Sonnenberg E. Hofmann AF. Horizons ingallstone therapy - 1988. A .I R 1988; 150: 43-6.8. Sauerbrueh T, Stern M and the Study Group forShoek - wave Lithotripsy of Bile Duet Stones.Fragmentation of bile duet stones by extraeorpo-real shoek waves. A new approaeh to biliary ealeuli after failure of routine endoseopie measu­res. Gastroenterology 1989; 96: 146-52. 9. Brown BP, Loening SA, Johlin FC. Dayton MT, Maher JW. Fragmentation of biliary traet stones by lithotripsy using loeal anesthesia. Arch Surg1988; 123: 91-3. 10. Nieholson DA, Martin DF, Tweedle DEF, and Rao PN. Management of eommon bile duet stones using a seeond - generation extraeorporeal shoek­wave lithotriptor. B .! Surg 1992; 79: 811-4. 11. Weber J, Adamek HE, Riemann JF. Extraeorpo­real piezoeleetrie lithotripsy for retained bile duetstones. Endoscopy 1992; 24: 239-43.12. Staritz M, Grosse A, Alkier R, Krzaska B und Meyer zum Busehenfelde KH. Terapie der Chole­doehlithiasis dureh extrakorporale Stoswellenlitho­tripsie und adjuvante operative. Endoskopie. Z Gastroenterol 1992; 30: 156-61.13. Binmoeller KF, Bruekner M, Thonke F, Soehen­dra N. Treatment of diffieult bile duet stones using meehanieal, eleetohyraulie and extraeorporeal shoek wave lithotripsy. Endoscopy 1993; 25:201-6. 14. Lindstrom E, Boreh K, Kullman EP, Tiselius HG,Ihse l. Extraeorporeal shoek wave lithotripsy ofbile duet stones: a single institution experienee. Gut 1992; 33: 1416-20.15. Adamek HE, Buttmann A, Hartmann CM, Ja­kobs R und Riemann F. Extraeorporeal piezoelek­trisehe lithotripsie von intra- und extahepatisehenGallengangssteinen. Dtsch Med Wschr 1993; 118: 1053-9.

Extracorporeal shock - wave lithotripsy in the management of bile duct stones

https://dirros.openscience.si/Dokument.php?id=24101&dn=

Extracorporeal shock - wave lithotripsy in the management of bile duct stones

Abstract

Similar works

Full text

Available Versions

Digital repository of Slovenian research organizations