Non-surgical management of bile duct stones refractory to routine endoscopic measures.
Endoscopic sphincterotomy and percutaneous approaches to the biliary tract have revolutionized the treatment of bile duct stones. Both the endoscopic and transhepatic approaches are less invasive than open surgery. This is an advantage for the mostly elderly and frail patients with common bile duct stones. Other patients with intrahepatic stones, e.g. young patients with oriental lithiasis, may also profit from the non-surgical approach. In this latter group it is often difficult for the surgeon to obtain access to the stone-bearing bile ducts. Due to the anatomical situation, size or impaction of stones the non-surgical approach, including mechanical disintegration, may primarily fail. Several techniques such as intracorporeal lithotripsy using electrohydraulic probes or laser light, extracorporeal shockwave lithotripsy or direct contact dissolution are now available and often allow complete clearance of the bile ducts. If a kidney lithotripter with radiographic devices is available, it should be used after an attempt at mechanical lithotripsy has failed (Figure 1). According to the literature, experience with this method is greater than with any other 'third-step approach'. The procedure is simple, relatively safe and successful in approximately 80% of patients. However, in at least one third of patients, several sessions have to be performed and further endoscopy is frequently required for extraction of fragments. Intracorporeal techniques may become the procedure of choice in the future, at least in patients with common bile duct stones. At the moment, however, the different devices are still not fully developed and too susceptible to damage. A further major drawback, especially with high-energy electrohydraulic intracorporeal lithotripsy, is the danger of bile duct injury or even perforation, so that most procedures must be performed under optical control. The use of contact dissolution cannot generally be recommended. Treatment with mono-octanoin or modified mono-octanoin solvents takes too long, is often not successful and has a high rate of side-effects. MTBE may shorten the procedure considerably, but is suitable only for cholesterol stones, and the danger of spill-over into the intestine with absorption and systemic side-effects has to be weighed against the probability of success.
Department of Internal Medicine, University of Bonn, Germany.
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Sauerbruch
D001647:Bile Acids and Salts / Q000627:therapeutic use; D001649:Bile Duct Diseases / Q000628:therapy; D002210:Caprylates; D002769:Cholelithiasis / Q000628:therapy*; D053138:Cyclohexenes; D004987:Ethers / Q000627:therapeutic use; D005989:Glycerides / Q000627:therapeutic use; D006801:Humans; D053685:Laser Therapy; D000077222:Limonene; D008096:Lithotripsy; D017602:Lithotripsy, Laser; D008738:Methyl Ethers; D012997:Solvents / Q000627:therapeutic use; D015607:Stents; D013729:Terpenes / Q000627:therapeutic use
D001647:Bile Acids and Salts; D002210:Caprylates; D053138:Cyclohexenes; D004987:Ethers; D005989:Glycerides; D008738:Methyl Ethers; D012997:Solvents; D013729:Terpenes; C043243:methyl tert-butyl ether; D000077222:Limonene; C025343:monooctanoin