title: Use of pneumatic lithotripsy for managing difficult CBD calculi.
abstract: BACKGROUND
  About 7-12% of patients who harbor gallbladder calculi concomitant common bile duct (CBD) calculi are present. The treatment of gallbladder calculi has standardized in the form of laparoscopic cholecystectomy but management of CBD calculi is still evolving. Endoscopic removal of CBD calculi <2 cm in diameter is successful in 90-100% of cases but patients harboring stones >2 cm in diameter high failure rates can be seen. Traditionally, laparoscopically one can achieve success rate comparable to endoscopic surgery but large and impacted calculi may cause failures. If one uses pneumatic lithotripsy during laparoscopic management of CBD calculi one can achieve 100% stone clearance irrespective of size, degree of hardness and impaction. This study evaluates the feasibility of using pneumatic lithotripsy for CBD calculi. To our knowledge this is the 1st reported series of using pneumatic lithotripsy for CBD calculi.
  
  
  METHODS
  From June 2002 to June 2010 96 laparoscopic CBD explorations (LCBDE) were done for CBD calculi. Patients having choledocholithiasis with CBD diameter of >10 mm were taken for LCBDE while in patients with CBD diameter of <10 mm were referred for endoscopic clearance. Additionally ERCP failure cases were also subjected to LCBDE. Rigid nephroscope was used for LCBDE and usually calculi were removed by forceps only. In patients having large, hard &/or impacted calculi pneumatic lithotripsy were used for fragmentation.
  
  
  RESULTS
  Out of the 96 patients in 12 (12.5%) cases pneumatic lithotripsy was used for stone fragmentation. Out of these 12 cases 5 (41.6%) were ERCP failure cases. At a mean hospital stay of 2.5 days 100% stone clearance was achieved in all cases with no perioperative complication.
  
  
  CONCLUSIONS
  The present study shows how successfully pneumatic lithotripsy can be used to fragment large, hard &/or impacted CBD calculi. Pneumatic lithotripsy being user friendly easily available can reliably fragment CBD calculi in one session.
authors.affiliation: Department of Minimal Access Surgery, Institute of Kidney and Urological Disease Research Center, Sonwar, Srinagar, India. drjavid11@gmail.com
authors.forename: Syed Javid
authors.initials: SJ
authors.lastname: Farooq Qadri
authors.forename: Muneer
authors.initials: M
authors.lastname: Khan
authors.forename: Naveed
authors.initials: N
authors.lastname: Khan
mesh_terms: D000328:Adult; D000368:Aged; D002760:Cholangiopancreatography, Endoscopic Retrograde; D015331:Cohort Studies; D005240:Feasibility Studies; D005260:Female; D042882:Gallstones / Q000150:complications / Q000473:pathology / Q000628:therapy*; D006801:Humans; D010535:Laparoscopy; D007902:Length of Stay; D008096:Lithotripsy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D055815:Young Adult