title: [Laser lithotripsy of refractory bile duct calculi after failure of extracorporeal shock wave treatment].
abstract: 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.
authors.affiliation: II. Medizinische Klinik, Technischen Universität München, Klinikum rechts der Isar.
authors.forename: P
authors.initials: P
authors.lastname: Born
authors.forename: H
authors.initials: H
authors.lastname: Neuhaus
authors.forename: M
authors.initials: M
authors.lastname: Classen
mesh_terms: 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
vernacular_title: Laserlithotripsie schwieriger Gallengangssteine nach Versagen einer extrakorporalen Stosswellenbehandlung.