[Laser lithotripsy of refractory bile duct calculi after failure of extracorporeal shock wave treatment].
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.


METHODS
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-cholangio-scopes. 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 %.


CONCLUSIONS
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.
Born
P
P
II. Medizinische Klinik, Technischen Universität München, Klinikum rechts der Isar.
Neuhaus
H
H
Classen
M
M
D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde; D004322:Drainage; D005260:Female; D042882:Gallstones / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D008096:Lithotripsy; D017602:Lithotripsy, Laser; D008297:Male; D017562:Postcholecystectomy Syndrome / Q000000981:diagnostic imaging / Q000628:therapy; D017211:Treatment Failure
Laserlithotripsie schwieriger Gallengangssteine nach Versagen einer extrakorporalen Stosswellenbehandlung.