Difficult bile duct stone recurrence after endoscopy and extracorporeal shockwave lithotripsy

BACKGROUND/AIMS: In a prospective study, we investigated stone recurrence in high risk patients with difficult common bile duct stones treated with extracorporeal shockwave lithotripsy (ESWL) after futile endoscopic attempts at stone extraction with sphincterotomy. METHODOLOGY: Endoscopic stone extraction proved unsuccessful in 35 of 659 patients presenting with common bile duct stones (5.5%, 11 males and 24 females: mean age 71.0+/-10.0 yrs; BMI 25.8+/-3.9; ASA-Classification 2.63+/-0.65), due to large stone size (10 patients), incarcerated stones (15 patients), stones inaccessible to the Dormia basket (7 patients) or an impacted Dormia basket (3 patients). The stones were localized radiologically. ESWL was performed using the HM3 lithotripter (Dornier, Munich/FRG). RESULTS: Immediately following ESWL, 17.1% of the patients treated showed complete stone clearance. In an additional 57.1%, further endoscopic stone extraction was required to achieve complete stone clearance, while 20.0% were discharged with small residual stone fragments. The remaining 2 patients (5.7%) required surgical intervention. Thirty four of 35 patients (97.1%) were followed-up for an average of 27 +/- 11 months. Five patients (14.3%) experienced stone recurrence at an average of 13.8 +/- 5.7 months post ESWL. CONCLUSIONS: ESWL is a useful and safe adjunct to endoscopic management of difficult common bile duct stones in older, high-risk patients. The stone recurrence rate was about 14% after one year. All recurrent stones were treatable by endoscopy.