title: Operative choledochoscopic laser lithotripsy for impacted intrahepatic gallstones: a novel surgical approach.
abstract: BACKGROUND
  Occasionally patients present with hepatic duct stones or impacted common bile duct stones that either fail or are not amenable to endoscopic retrograde cholangiopancreatography (ERCP) extraction. More troublesome are patients with prior surgeries resulting in altered anatomy that makes traditional endoscopic extraction of ductal stones very difficult. We present a novel approach to these ductal stones using a combination of surgery, biliary endoscopy, and laser lithotripsy.
  
  
  METHODS
  We report on five patients with ductal stones that either failed ERCP or were not candidates for ERCP extraction. Data was collected via chart review with Institutional Review Board approval.
  
  
  RESULTS
  The average age of patients was 70.1 years. All patients presented with hepaticolithiasis and symptoms of cholangitis including elevated liver function tests and recurrent fever and chills. Patients had a mean of 2.8 failed ERCP or percutaneous attempts at stone clearance (range 2-4). A combination of surgery and intraoperative biliary endoscopy with laser lithotripsy (holmium laser) was used in all patients. In four patients the lithotripter was introduced via a choledochotomy or hepaticodochotomy. One patient had previously undergone a Roux-en-Y hepaticojejunostomy and was found to have a large hepatic duct stone sitting above a strictured anastomosis. Access was gained via an enterotomy in the Roux limb. Complete stone clearance was obtained in all patients. Average operative time was 349 min. All patients have normal liver function tests (27-36 month follow-up).
  
  
  CONCLUSIONS
  Laser lithotripsy has been described as an adjunct to ERCP in the past for stones refractory to balloon or basket retrieval. The combination of a surgical enterotomy, biliary endoscopy, and laser lithotripsy provides a novel approach to treat patients with large intrahepatic stones who are not candidates for or have failed ERCP.
authors.affiliation: Department of Surgery, Mary Imogene Bassett Hospital, 1 Atwell Road, Cooperstown, NY 13326, USA. kenneth.bark@bassett.org
authors.forename: Kenneth
authors.initials: K
authors.lastname: Bark
authors.forename: T Clark
authors.initials: TC
authors.lastname: Gamblin
authors.forename: Randall
authors.initials: R
authors.lastname: Zuckerman
authors.forename: David A
authors.initials: DA
authors.lastname: Geller
mesh_terms: D000368:Aged; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D002768:Choledochostomy; D015331:Cohort Studies; D004724:Endoscopy; D006500:Hepatic Duct, Common; D006801:Humans; D017602:Lithotripsy, Laser / Q000379:methods*; D011859:Radiography; D012189:Retrospective Studies; D016896:Treatment Outcome