Dither

H. Bonnel,

Common Results Lithotripsy

MD

Claude

#{149}

E. Liguory

Index terms: Bile ducts, calculi, 76.289 #{149}Bile ducts, interventional procedure 76.1228, 76.1229 #{149}Bile ducts, stone extraction, 76.1228, 76.1229 #{149}Uithotripsy, 762.1299 #{149}Liver, calculi, 761.289 #{149}Liver, interventional procedure, 761.1229 1991; 180:345-348

I

1987, we presented our preliminary results of performing intracorporeal electrohydraulic shock wave lithotripsy of common bile duct stones in seven patients (1). The purpose of this article is to report our technical improvements, since the nature of the complications in this current series led us to modify our technique. We also report the current results of and indications for this procedure.

MATERIALS From

Radiologique,

15 Avenue

Robert Schuman, 75007 Paris, France (D.H.B., F.E.C.); and Centre Medicochirurgical de l’Alma, Paris (J.F.P.L., C.E.L.). Received September 24, 1990; revision requested October 22; final revision received March 27,1991; accepted April 1. Address reprint requests to D.H.B. #{176}RSNA, 1991

AND

October

METHODS

to December

1986

1990,

50 patients were referred for percutaneous lithotripsy of common bile duct or intrahepatic stones. There were 33 women and 17 men. The mean age was 65 years ± 17.

Of the 27 patients with common bile duct stones, 20 had undergone previous endoscopic sphincterotomy, but extraction of the stones and attempts at methamcal lithotripsy failed (2). In seven patients, endoscopic papillotomy failed because of the presence

of a Billroth

H anastomosis.

All of

these patients had clinical symptoms of biliary obstruction: Twenty-two had cholangitis, five had jaundice. Fifteen patients had solitary stones; 12 patients, multiple stones. The mean diameter of the stones was 1.8 cm ± 0.5.

Of the 23 patients with intrahepatic stones, 14 had primary intrahepatic lithiasis with multiple stones involving both lobes. These patients had undergone an endoscopic

sphincterotomy,

but

extraction

of the stones

failed. Nine patients had intrahepatic lithiasis secondary to a strictured bilidigestive anastomosis: seven patients with a strictured hepaticojejunostomy and two patients with a strictured choledochoduodenostomy. Six of these nine patients had a solitary stone; three multiple

trahepatic

Clinique

#{149} Jean-Fran#{231}ois

N

had ‘From

Cornud

Bile Duct and Intrahepatic of Transhepatic Electrohydraulic In 50 PatIents’

Percutaneous, transhepatic, intracorporeal, electrohydraulic shock wave lithotripsy was performed in 50 patients after failure of endoscopic treatment (n = 43) or directly in patients with a strictured hepaticojejunostomy (n = 7). Twenty-seven patients had common bile duct stones; 23, intrahepatic stones. Three steps were used: A transhepatic bificutaneous fistula was created, a wide cornmunication between the bile duct and the gut was established, and contact shock wave lithotripsy was performed under endoscopic guidance. Afterward, 46 patients were free of stones. In four patients with diffuse intrahepatic lithiasis, only 75% of stones could be cleared. Severe cornplications, seen in 11 patients (hernobilia necessitating transfusion [it = 6k bile duct perforation resulting in cholangitis In = 31, acute pulmonary ederna [n = 1J, and hernothorax [n = 11), were fatal in four patients; all occurred early in the study. The authors modified their technique by dilating the biliary tract in two sessions 3 days apart, waiting 6 days for the tract to mature, and then introducing the cholangioscope directly through the skin, significantly reducing complications and mortality (P < .005).

Radiology

#{149} Fran#{231}oisE.

of bifiary jaundice,

stones. lithiasis

obstruction n = 3).

!ntracorporeal

was

All patients had

performed

shock

with

in-

dinical

symptoms (cho!angitis, n = 20; wave

in a stepwise

lithotripsy fashion.

As

we observed a high rate of severe complications in our early experience, modifications of the technique were introduced after December 1988. Both techniques will

P. Lefebvre

Stones:

be described.

All the transhepatic

vers were performed pitalized and under

with

the

maneupatient

hos-

general anesthetics (dextromoramide or propofol). The patient received an antibiotic (cefoxitin) intravenousby from admission until discharge. Percutaneous access to the biliary tract was provided by performing a conventional percutaneous biliary drainage (3). In all patients

stones, created tients tients.

a single through and

through

with

common

percutaneous

the right

bile duct tract

was

lobe in 22 pa-

the left lobe

in five pa-

The right access route was preferred because it lessened the radiologist’s x-ray exposure. The left approach was used when the intrahepatic ducts were barely dilated. For patients with intrahepatic mined

the

lithiasis, access routes were deterby the location of stones. Stones right lobe were usually reathed

in

through a left approach; stones in the left lobe were usually reathed through a right approach. In the nine patients with stones above a strictured bilidigestive bypass, a single transhepatic approach was necessary through the right lobe in four cases and through the left lobe in five cases. In 14 patients with stones in both lobes, multiple tracts were necessary: two tracts each in 11 patients and three tracts each in three patients. Introduction of the tholangioscope into the biliary system required dilation of the tract to 20 F. The dilation was performed with renal dilators (Amplatz; Cook, Bagnolet, France). Early in

our

study

(from

October

1986

to December

1988), in the first 30 patients, biliary drainage and tract dilation to 20 F were performed during the same session. An 18-F cutaneous ureterostomy catheter (Porges, Palaiseau, France) was then inserted as a stent in the tract. FromJanuary 1989 to October 1990, in the last 20 patients, dilation of the tract was achieved in two sessions. The biliary drainage and dilation of the tract up to 14 F were performed on the first day. A 14-F cutaneous ureterostomy catheter (Porges) was inserted. Dilation of the tract up to 20 F was achieved on the third day and was followed by insertion of an 18-F cutaneous ureterostomy catheter. A wide communication between the biliary system and the gut had to be provided to permit easy dearance of stone fragments and irrigation fluid through the 345

intestine.

Thirty-four

endoscopic tients,

patients

endoscopic

In seven

papillotomy

percutaneous omy

was

performed

in four

of the

formed

in three

patients,

viously

described

a 5-mm

bilidigestive

dilation

France).

wire.

in the

A second

tract guide.

in our Because

the

endoscope

20-F

metallic

via

wire

was

we tract

was

was a guide

left in the

performed the

chol-

dilation

was

not

through

(Olympus)

system

coaxially

/

of the

mature,

introduced

sheath

in the biliary renal

duct

after

the

a 2-mm

endoscope

as a security

study,

3 days

Me-

fiberscope with

cholangioscopy

angioscopy tract.

bile

guide

during

Early

This

The

a

SCOP

caliber

channel.

introduced

/

of the stric-

(Olympus;

external

operating

to preIn nine

prior to lithotripsy. was performed with

Rungis,

has

per-

(4,5).

a strictured

PlO endoscope

decine,

and

was

according

balloon

was performed Cholangioscopy

CHF

patients,

papilla

techniques

with

anastomosis,

A

sphincterot-

dilation

patients

pa-

failed.

transhepatic

balloon

ture

underwent

sphincterotomy.

a

over

an 18-F

dilator.

More

recently,

waited

since

6 days

tion

for

the

after

through

performed

tion

with

skin.

ZA des

Then

an

rate

Stones

set

lithotripsy

pump

France) with by

(Walz;

waves

of 40 impulses

were

SCOP

second.

gut

irrigation

with

with

the

The

en-

per impulse. cleared into

or were

the

pushed

endoscope.

intrahepatic

with

in 2-second

per

set to 0.26 joules of stones were

through

M#{233}decine).

in contact viewing.

released

ergy was Fragments with

a 3-F

to an elec-

The electrode was brought the stone under endoscopic Shock

electrohy-

produced

connected

bursts

with

mljmin.

waves

generator

was

(Hemocare;

Eaubonne,

probe

tronic

fluid

fragmented

shock

irriga-

irrigation

at 60-100

were

draulic

cholangioscopy

electric

Abouettes,

a flow

and

directly

continuous

The

with

we

of dila-

tract,

introduced

under

saline.

1989,

of the

was

the

was injected

January

the last session

maturation

the endoscope

In patients in-

of the intrahepatic

ducts,

it was

sometimes

difficult

the

the distal stones.

to position

duct

these

the

cases,

ducts

were

fluoroscopic

then

via

a guide

After

terial-enhanced At the

cutaneous

priate

end

the

for

of the

3 days

patency

in all

346

and

cholangiogram

shows

diffuse

intrahepatic

lithiasis.

A nasobil-

Radiology

ma-

of the

then

a 14-F was

removed

was

considered with

left after

and we believed was necessary

In all 27 patients with common duct stones and all nine patients secondary intrahepatic lithiasis, corporeal lithotripsy permitted

ance

appro-

a strictured

RESULTS

per-

bile

At cholangiogra-

patients

dilation.

#{149}

transhepatic

iary drainage tube (arrowhead) had been previously placed. (b) The metallic sheath (arrowhead) was introduced into the biliary system through the eighth right intercostal space. This approach allowed lithotripsy of large stones (arrows) in the right hepatic duct. (c) For lithotripsy of stones (short arrows) in the distal right intrahepatic duct, the metallic sheath (arrowhead) was introduced through the left duct. The endoscope was advanced over a guide wire (long arrow). (d) Contrast-enhanced cholangiogram obtained after lithotripsy shows clearance of intrahepatic ducts.

and was

catheter

digestive anastomosis, that no stent placement ter

stones

procedure,

cholangiography. the

was

posi-

contrast

status

ureterostomy

in place phy,

of the fragments,

cholangiography

to check

ducts.

under endoscope

(a) Percutaneous

wire.

of the

formed

the

an appropriate

fragmentation

elimination

in

containing

The

into

scope

stone-contain-

catheterized

guidance.

introduced

tion

and

intrahepatic In

ing bile

lithiasis

C.

diffuse

volvement

final

b.

a.

advanced

bii-

af-

patients lithiasis,

of stones

in one

with primary only stones than 5 mm in diameter mented and cleared

session.

bile with intraclear-

In i4

intrahepatic in ducts greater could be frag(Figure). Stones

in the distal left in place

intrahepatic whenever

be dislodged these patients ter

two

tients,

with irrigation. Ten were free of stones

or three only

about

sessions. 75%

be cleared. The mean was 14 days ± 3. The

and

the

secondary

duct were they could not

follow-up intrahepatic

In four of stones

of afpacould

in-hospital stay clinical history

in patients

with

lithiasis

August

is

1991

Clinical

and Follow-up after Percutaneous Intracorporeal Treated for Infrahepatic Stones Above Strictured

History

Nine Patients Anastomoses

Clinical

Patient

NoJ

SeWAge(y)

Year/Follow-up Procedure,’ Recurrent Biliary

Disease

1JM/38

Follow-up

1979/endoscopic papifiotomy/re-

sidual

In one Duration

(mc/y)

Doing

chronic caused

(mo)

Findings*

3/89

well

right

stones

stones 1974/Ca/gall-

3/M/76

stones 1988/CCT

and HJ/

gallstones

duct

6hl/96

7/M/64

Doing

well

20

5/9

Doing

well

19

1983/I-IJ/recurrent stones

1/88

Left

hepatectomy for recurrent stone

24

and

treated

successfully

drainage.

Minor

the was

4/88

Doing

well

32

Residual duct stones

NF

4/88

Doing

well

32

sphincterotomy ous extraction

1982./CD/residual

HJ/

NF

1/89

Doing

5/89

Died

well

24

of hemobilia

6d

10/90

Doing

well

HJ

=

hepaticojejunostomy,

NF

(after tripsy

tients, clinical and biochemical low-up showed no recurrent obstruction.

Massive

In two

bleeding

during

introduction

patic showed,

fistula

in 11

hemobiia requiring occurred in six patients.

cases,

occurred

ously. sistent

the

folbiiary

occurred

occurred

mediately after percutaneous of the tract. In four cases,

case

pa-

(22%) and were fatal in four (8%). All these severe compliwere observed early in our

transfusion

hemobilia

dilation bleeding

sheath.

arteriogram

spontane-

=

follow-up.

at the

obtained. an

This

arteriobiliary

point

of entry

into the biliary tract (right lobe of liver, one patient; left lobe of liver, four patients). In all patients, the catheter could be advanced selectively in

Volume

180

Number

#{149}

2

damaged

arterial

branch.

Thera-

peutic embolization was achieved with glue in five patients (Ethibloc: Ethnor, Neuilly-sur-Seine, France [two patients]; and Histoacryl: Bruneau,

Boulogne,

France

[three

pa-

as ob-

tients, resulted

aged 78 and 83 years, in fatal hypotension.

bleeding With

the new technique, no bleeding related to arterial hepatic damage was observed. This difference is statistically significant (P < .005 with x2 correction).

Perforation of an intrahepatic with the endoscope was observed

duct in

three

lithia-

patients

with

sis. These perforations the endoscope was in the scopic

bile ducts viewing.

recognized tients, the

intrahepatic

occurred when advanced distally

without clear As perforations

immediately procedure

was

endowere

in all painterrupted

bile are

basket

common

be trapped

(Olympus,

with

SCOP

of stone

extraction

mechanical cholangioscopic

litho-

procedures) occurs in 1 % of the patients referred for endoscopic treat(8).

Extracorporeal

lithotripsy

in approximately patients

(9,10).

is

75% Although

of failure

of both endoscopic treatment and extracorporeal lithotripsy is uncommon, such cases percutaneous

thyl

are

suitably lithotripsy.

tert-butyl

(11,12)

tients]). In these five patients, bleeding stopped immediately after embolization. However, in two pa-

Yates

with severe peremergency he-

was

in all cases,

after In one

stopped

In five patients bleeding, an

located

im-

cholangioscopy

of the

techniques of the bile

in the

cannot

conventional and peroral

these

complications

no

endoscopic

impacted

that

effective other

with

M#{233}decine). Failure

2

ment

Severe

with

(6) or with percutanewhen a T tube is in

stones

duct

a Dormia

Note-Ca = cholecystectomy, CD = choledochoduodenostomy, no follow-up until percutaneous treatment. *The finding of doing well is based on clinical and biochemical

patients patients cations study.

simple

or recurrent common after cholecystectomy

either

large

bie 1987/NJ/common

In the

with hemobilia

a was

place (7). The usual causes of failure of endoscopic treatment are unsuccessful endoscopic papillotomy and

bile duct stones

Table.

pulmowith

duct caused by the shock wave served during cholangioscopy.

treated

1972,’CCT/gall-

in the

acute

new and the old related to injury

NF

stones

given

in a fatal

In one patient route, hemothorax

access

both and

gallstones and common bile duct stones 9/F/56

with overload of sa-

loss in hematocrit occurred in 10 patients. This hemobilia occurred with

stones

1985/Ca

patient

DISCUSSION

stones 8/M/78

75-year-old

stones

1984/resection of common bile duct and HJ/cholangiocarcinoma 1985/Ca and CD/ gallstones and common bile duct stones 1972./Ca/gall-

5/M178

4/89

and

common bile duct stones 1980/Ca and surgical papillotomy/gallstones and common bile

4/M/44

(postoperative stricture) NF 1975/HJ

was in

cardiac failure, fluid by intestinal absorption

line resulted nary edema.

21

1980/HJ/recurrent 2/F/65

catheter occurred

these three patients and was controlled with medical therapy in two patients. In one patient, septic shock was fatal.

Treatment

Date of Treatment

Disease

1972/Ca/gallstones

and a biliary drainage inserted. Cholangitis

in

Bilidigestive

Percutaneous

History

Year/Initial Surgical Procedure/ Initial Biliary

Lithotripsy

has

for in situ

patic

ducts,

ineffective

of common

intrahepatic by multiple

involvement frequent

with of me-

or monooctanoin

relatively

dissolution

duct stones. Primary characterized

diffuse

ether been

managed Use

bile

lithiasis stones

of the

is with

intrahe-

abnormalities

of

the intrahepatic ducts with stenosis and saccular dilatations, frequent reformation of stones after treatment, and ary

and

ultimate biliary

progression to secondcirrhosis. Duodenoscopy

extracorporeal

successful

Surgical

in these

treatment

lithotripsy diffuse

are not lithiases.

is lobectomy

but

only in patients with unilobar involvement. Patients with diffuse involvement are good candidates for intracorporeal lithotripsy. Secondary

intrahepatic

lithiasis

is often

caused

Radiology

#{149} 347

by a stricture of a bilidigestive anastomosis. Surgical repair of a bilidigestive anastomosis is often difficult, espeaally in patients who have undergone multiple operations on the bile ducts. Whenever possible, however, surgical

repair

is safe

and

effective

(13). Percutaneous dilation of a sb-ictured bilidigestive anastomosis is presently an alternative in poor surgical candidates (14). When stones are present, intracorporeal electrohydraulic lithotripsy can follow percutaneous dilation of the anastomosis. Percutaneous transhepatic intracorporeal lithotripsy is effective in our experience. The shock wave is powerful at the tip of the electrode but weakens rapidly with distance. Positioning the electrode directly in contact with the stones, under endoscopic viewing, provides

optimum

efficacy

and

obvi-

ates injury to the bile duct wall. A wide communication between the bile duct and the gut permits elimination of fragments up to 1 cm in diameter into the intestine. This allows rapid elimination of large stones. Irrigation under pressure was necessary to provide sufficient flow through the 2-mm operating channel partially obstructed by the lithotripsy electrode. In this study we report a 22% rate of severe complications with 8% mortality. In a recent article, Picus et al (15) used the same technique in six patients. They did not report any complications despite the use of a Teflon sheath and acute dilation of the transhepatic tract in three patients. Nimura (16) reported 239 cholangioscopic procedures with no severe complications. These authors progressively dilated the b-act in 3 weeks. Bleeding was, in our study, the most frequent and serious complication. It was due to damage to a hepatic arterial branch at the point of entry into the bile duct, as shown by arteriography in five patients. This frequency of severe bleeding is much higher than usually observed in conventional biliary drainage (17). Arterial lesions are created by the puncture and are probably enlarged by dilation of the tract and introduction of the sheath. Mitch-

348

#{149} Radiology

eli et al (18) also found an 8.9% versus a 2.3% hemobtha rate in large-caliber (19-24-F) versus small-caliber (8.310-F) transhepatic tracts. In our experience, the rate of hemobilia significantly decreases with progressive dilation and maturation of the tract. This progressive dilation probably allows arterial wounds to heal. Maturation of the tract, which occurred by 6 days after a catheter was placed as a stent, allowed easy introduction of the endoscope into the biliary system through the skin orifice. This obviated the use of a rigid sheath, which can possibly create parenchymal damage during endoscopic manipulations. When arterial bleeding does occur, we advocate the immediate performance of arteriography with eventual embolization, because hemobilia caused by an arteriobiliary fistula rarely stops spontaneously. Bile duct perforation occurred when we attempted to advance the endoscope into distal biliary branches without clear endoscopic viewing. These perforations caused by the endoscope are extremely serious because of the risk of cholangitis and should therefore be avoided at all cost. The endoscope should be advanced only when the biliary lumen is clearly visible. Whenever endoscopy of a distal intrahepatic duct is difficult, it can be eased by positioning a guide wire under endoscopic gridance. In conclusion, the results of our study indicate that intracorporeal shock wave lithotripsy is an effective method that can be used in selected patients who have common bile duct or intrahepatic stones at initial diagnosis. The high rate of severe complications early in our study has been lowered considerably by improvement of the technique. #{149}

3.

4.

Percutaneous

5.

6.

7.

8.

9.

10.

2.

Berkman Cashman

11.

tion of the distal common bile duct and ampulla of Vater for removal of calculi. Radiology 1988; 167:453-455. Classen M, Ossenberg FW. Nonsurgical removal of common bile duct stones. Gut 1977; 18:760-769. Burhenne HJ. Percutaneous retained biliary tract stones: AJR 1980; 124:888-898.

13.

14.

15.

extraction

of

661 patients.

Liguory CL, Lefebvre JF, Bonnel D, Comud F, Etienne JP. Indications for cholangioscopy. Endoscopy 1989; 21:341-343. Becker CD, Fache JS, Cibney RC, Scudamore CH, Burhenne HJ. Choledocholithiasis: treatment with extracorporeal shock wave lithotripsy. Radiology 1987; 165:407408. Liguory CL, Lefebvre JF, Beaugerie L, et al. Lithotritie extra-corporelle: r#{233}sultats pr#{233}-

chez

5 malades

ayant

des

calculs

de la voie billaire principale. Presse Med 1987; 16:1505-1507. Teplick 5K, Haskin PH, Goldstein RC, et al. Common

12.

sphincterotomy

of biliary tract disease. 1986; 11:273-276.

WA, Bishop AF, Palagallo CL, MD. Transhepatic balloon dila-

liminaires

bile

duct

stone dissolution

with

methyl tertiary butyl ether: experience with three patients. AJR 1987; 148:372-374. Haskin PM, Teplick 5K, Sammon JK, et al. Monooctanoin infusion and stone removal through the transparenchymal tract: use in 17 patients. AJR 1987; 148:185-188. Pitt HA, Kaufman SL, ColemanJ, White RI, Cameron JL. Benign postoperative biliary strictures: operate or dilate. Ann Surg 1989; 210:417-427. Molnar W, Stockum AE. Transhepatic dilatation of choledochoenterostomy strictures. Radiology 1978; 129:59-64. Picus

D, Weyman

PJ, Marx

MV.

Role

of

percutaneous intracorporeal electrohydraulic lithotripsy in the treatment of biliary tract calculi: work in progress Radio!16.

ogy 1989; 170:989-993. Nimura Y. Percutaneous

transhepatic

cholangioscopy (VFCS) in the treatment of intrahepatic stones. In: Sheen PC, Ker CC,

eds.

Gallstones

and choledochoscopy. 1984; 71-85. Mueller PR, Butch RJ, Bonnel D. Percutaneous biliary drainage results and compli-

Nagoya,Japan: 17.

Liguory CL, Bonnel D, Canard JM, Cornud F, Dumont JL. Intracorporeal electrohydraulic shock wave lithotripsy of common bile duct stones: preliminary results in 7 cases. Endoscopy 1987; 19:237-240. Liguory CL, Lefebvre JF, Bonnel D, Cornud F. Usefulness of different methods of lithotripsy for common bile duct stone. Ada Gastroenterol BeIg 1988; 51:251-256.

transhepatic

in the management Castrointest Radiol

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JTJr, Mueller PM. Biliary drainage: indications, instrumentation and technique. In: Ferrucci JT Jr, WittenbergJ, Mueller PR, Simeone JF, eds. Interventional radiology of the abdomen. Baltimore: Williams & Wilkins, 1987; 184-218. Coboum C, Makowka L, Ho CS, et aL Ferrucci

cations.

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SE, Shuman

Mueller 18.

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August1991