LASERLITHOTRIPSY OF DIFFICULT BILE-DUCT STONES AFTER FAILURE OF EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY

After failure of extracorporeal shockwave lithotripsy (ESWL) the benefit of further nonsurgical methods for treatment of difficult bile duct stones is undetermined. Endoscopic laserlithotripsy is a promising procedure providing target application of high energy levels. Method: Twenty patients (median age: 81 [67-91] years) were referred for laserlithotripsy of 1-8 (median, 2) difficult bile duct stones after failure of 1-4 (median, 3) ESWL sessions. The median diameter of each of the largest stone was 22 (10-48) mm. The laser used was a pulsed rhodamine laser (wavelength: 594 nm) with an automatic cut-out system upon no stone contact. The laser fiber was positioned by means of ERCP under fluoroscopic control or by use of mini-cholangioscopes. Laserlithotripsy was cholangioscopically performed via the percutaneous transhepatic route in 8 patients because of retrogradely inaccessible bile ducts (n=5) or because further ERCP was refused (n=3). All procedures were carried out under intravenous sedation and/or analgesia. Results: Laser lithotripsy and complete removal of fragments was achieved in 19 of the 20 patients after application of 70-25700 (median, 3310) pulses in 1.2 sessions per patient. Median duration of a single session was 70 (15-140) minutes. The procedure failed in one patient with an impacted stone at the cystic duct confluence. Cholangitis could be conservatively managed in 2 cases. No further complication was observed. The 30-day mortality rate was 0 %. Conclusion: Endoscopic laserlithotripsy is an effective, a rapid and safe procedure for bile duct stones even after failure of ESWL. The results compare favorably with open surgery, particularly in view of an increased risk in a group of elderly patients.