NEW INSTRUMENTS AND NEW METHODS
Endoscopic Lithotripsy in the Common Bile Duct H. Koch, M. Stolte, V. Walz Medical Department of the University of Erlangen-Nuremberg
Summary
Endoskopische Lithotripsie im Gallengang
After appropriate preliminary experiments in animals and in corpses, electrohydraulic litho-
Nach einer Reihe prdliminarer Experimente an Tieren und Verstorbenen wurde das Verfahren
tripsy has been used for the first time in humans in an attempt to destroy stones in the bile duct. For this purpose, a lithotripsy probe combined with a Dormia basket was constructed. To date,
der elektrohydraulischen Lithotripsie erstmals beim Menschen angewandt, um Choledochuskon-
this method has been successfully applied to break fragments off large calculi in three pa-
körbchen armiert. Bislang- konnte diese Methode erfolgreich bei drei Patienten eingesetzt werden, um Fragmente aus grofien Konkrementen herauszubrechen. Komplikationen wurden nicht beob-
tients, without any complications arising. In one case, subsequent extraction of the remaining part of the stone was possible. The probe must, how-
ever, be improved to ensure that the stone is always held centrally in the basket.
Key-Words: Endoscopic lithotripsy, gallstone,
kremente zu zertrömmern. Zu diesem Zweck wurde die Lithotripsiesonde mit einem Dormia-
achtet. In einem Fall konnte der so verkleinerte Stein extrahiert werden. Die Sonde bedarf noch einer Verbesserung, um den Stein immer zentral im Körbchen fassen zu können.
common bile duct, endoscopic papillotomy.
Endoscopic papillotomy is, without doubt, a method of considerable diagnostic value.
located intrahepatically, but the most frequent cause of extraction failure is the large size of
The main indication for EPT, is calculi in the common bile duct in a post-cholecystectomy status, or in high-risk patients. Experience
the calculus. For this reason, a method was
to date shows that some two-thirds of all stones in the common bile duct can be passed spontaneously after an adequately large papillotomy. In 20°/o of the patients, the stones can be grasped and extracted with the aid of a Dormia basket, in ION of the cases extraction of the stones is not possible. Extraction is
sometimes impossible in the case of stones
thus sought, with the aid of which it might be
possible to split up such large calculi. With such a method, the splitting of the stones into two or three fragments would be adequate to make possible their subsequent extraction. Initial experiments with the aid of electro-
hydraulic lithotripsy showed that even large stones can be split with this method. In animal experiments, however, perforation of the common bile duct occurred in one third of the ex-
Downloaded by: Universite Laval. Copyrighted material.
Endoscopy 9 (1977) 95-98 0 Georg Thieme Verlag, Stuttgart
96
H. Koch, M. Stolte, V. W alz
Fig. 1
Fig. 2
Lithotripsy-probe with Dormia basket.
perimental animals. Additional experiments confirmed the suspicion that the perforations were not caused by the pressure wave produced by the lithotripsy probe, but by fragments of the "exploding" stone. For this reason, the lithotripsy probe was combined with a Dormia basket, in which the calculi can be grasped and retained, also during smashing.
Method and Patients Electrohydraulic lithotripsy is based on the principle that spark discharges in a liquid me-
dium give rise to steep hydraulic pressure waves. These waves are of such high energy that they can smash stones into fragments. Lithotripsy probe: the most important part of the lithotripsy probe is the spark chamber which is open to the front. It contains two rod
electrodes. Into the inside of the probe, in addition to the electric leads for the rod elec-
trodes, a further channel opens, into which liquid can be sprayed from outside. This liquid
is necessary for the production of the pressure wave. The sparkover is trigered and controlled
by a surge current generator (the Lithotron, manufactured by the firm of Walz, 7271 Rohrdorf) (Fig. 1). In the tip of the lithotripsy probe, a Dormia basket has been integrated. The four "arms" of the basket, embrace the spark cham-
ber from the outside and, in this way, enable the calculus to be drawn centrally up to the opening in the tip of the probe and fixed there. To permit the introduction of the probe, the
external diameter of which is 2.7 mm, the basket can be completely withdrawn (Fig. 2).
With this probe, initial attempts at destroying stones were carried out in the common bile ducts of 20 corpses.
Following theses experiments, electrohydraulic lithotripsy was then attempted in three patients in whom stones in the common bile duct were so large that they could not be extracted even after extensive papillotomy.
Downloaded by: Universite Laval. Copyrighted material.
Generator Lithotron.
Endoscopic Lithotripsy in the Common Bile Duct
97
Fig. 4 Stone crushed with electro-
hydraulic lithotripsy.
In the case of all three patients, the common bile duct was first filled, retrograde, with con-
the probe channel. Finally, the spark discharges were triggered (Fig. 4).
trast medium to facilitate the localization of the stones. Then, the lithotripsy probe was introduced. On account of the large diameter
Results
of the probe, an endoscope with an adequately wide-lumened instrument channel was necessary. To satisfy this requirement, the GFB-2 long endoscope manufactured by Olympus, Hamburg, was employed. After introducing the probe into the common bile duct, the Dor-
mia basket was advanced, the stone "captured" and then drawn up against the tip of the probe (Fig. 3). Then, to enable particularly
powerful pressure waves to be produced, a hypertonic liquid made up of 300/o glucose and physiological saline solution, was instilled via
In the experiments on corpses, all the calculi introduced into the bile duct were smashed. No lesions occurred in the bile duct. In all three patients, it was possible to break
fragments of the calculi. Subsequent stone extraction, however, was possible in only a single case (Figs. 5 and 6). No complications were observed. Discussion The experimental studies in the corpses have
shown that the lithotripsy probe combined with a Dormia basket permits the destruction
Downloaded by: Universite Laval. Copyrighted material.
Fig. 3 Stone catched in lithotripsy probe.
H. Koch et al.: Endoscopic Lithotripsy in the Common Bile Duct
Fig. 5 Stone catched in lithotripsy probe.
Fig. 6 Fragmented stone.
of stones. Initial attempts to employ this
reliably captured and held centrally. Appropriate efforts are presently being made. Such
method in the living patient only partly confirmed the results with corpses. Thus, to date, in clinical application, it has proved possible only to break small fragments off the stones. In these cases, this lack of success has clearly been due to the inability to capture the calculi with the Dormia basket in such a way that they
can be located centrally in front of the opening of the lithotripsy probe. The X-ray pictures obtained during the attempts to destroy the stones clearly indicate that the latter were located in the basket in such a way that the tip
of the lithotripsy probe was directed more tangentially to the margin of the calculus. In all the cases, despite repeated attempts, it was not possible to position the calculi centrally in the basket. The consequence of this is that the Dormia basket of the lithotripsy probe must be improved to ensure that the stones can be
efforts appear justified since it has been shown that even with a less than optimal position of the lithotripsy probe in the bile duct, no complications have occurred and that, despite the problems, one calculus was reduced in size to such an extent that its extraction became possible. An additional points is that, to date, no other method for the removal of large
bile duct calculi with a tolerable expenditure of time and effort has been developed. References Jvancevic, L.: Die elektrohydraulische Lithotripsie. Dtsch. med. Wschr. 96 (1971) 485
Koch, H., D. Belohlavek, M. Stolle, M. Clamen, V. Becker: Papillotomie und Steintherapie im Gallengang - Klinische Erfahrungen. In: R. Ottenjann, Fortschritte der Endoskopie. Schattauer, Stuttgart 1975 Koch, H., D. Belohlavek, O. Schaffner, M. Stolle, V. Walz: Lithotripsie im Choledochus. In: W. Rösch, Fortschritte der Endoskopie. Verlag Dr. Sträube, Erlangen 1976
Reuter, H.-J.: Electric treatment of bladder stones. Endoscopy 1 (199) 13
Priv.-Do:. H. Koch, Med. Univ.-Klinik, 8520 Erlangen, Dr. M. Stolle, Path. Inst. d. Univ., 8520 Erlangen Dipl.-Ing. V. Walz, Walddorfer Str 40, 7271 Rohrdorf
Downloaded by: Universite Laval. Copyrighted material.
98
Endoscopic Lithotripsy in the Common Bile Duct H. Koch, M. Stolte, V. Walz Medical Department of the University of Erlangen-Nuremberg
Summary
Endoskopische Lithotripsie im Gallengang
After appropriate preliminary experiments in animals and in corpses, electrohydraulic litho-
Nach einer Reihe prdliminarer Experimente an Tieren und Verstorbenen wurde das Verfahren
tripsy has been used for the first time in humans in an attempt to destroy stones in the bile duct. For this purpose, a lithotripsy probe combined with a Dormia basket was constructed. To date,
der elektrohydraulischen Lithotripsie erstmals beim Menschen angewandt, um Choledochuskon-
this method has been successfully applied to break fragments off large calculi in three pa-
körbchen armiert. Bislang- konnte diese Methode erfolgreich bei drei Patienten eingesetzt werden, um Fragmente aus grofien Konkrementen herauszubrechen. Komplikationen wurden nicht beob-
tients, without any complications arising. In one case, subsequent extraction of the remaining part of the stone was possible. The probe must, how-
ever, be improved to ensure that the stone is always held centrally in the basket.
Key-Words: Endoscopic lithotripsy, gallstone,
kremente zu zertrömmern. Zu diesem Zweck wurde die Lithotripsiesonde mit einem Dormia-
achtet. In einem Fall konnte der so verkleinerte Stein extrahiert werden. Die Sonde bedarf noch einer Verbesserung, um den Stein immer zentral im Körbchen fassen zu können.
common bile duct, endoscopic papillotomy.
Endoscopic papillotomy is, without doubt, a method of considerable diagnostic value.
located intrahepatically, but the most frequent cause of extraction failure is the large size of
The main indication for EPT, is calculi in the common bile duct in a post-cholecystectomy status, or in high-risk patients. Experience
the calculus. For this reason, a method was
to date shows that some two-thirds of all stones in the common bile duct can be passed spontaneously after an adequately large papillotomy. In 20°/o of the patients, the stones can be grasped and extracted with the aid of a Dormia basket, in ION of the cases extraction of the stones is not possible. Extraction is
sometimes impossible in the case of stones
thus sought, with the aid of which it might be
possible to split up such large calculi. With such a method, the splitting of the stones into two or three fragments would be adequate to make possible their subsequent extraction. Initial experiments with the aid of electro-
hydraulic lithotripsy showed that even large stones can be split with this method. In animal experiments, however, perforation of the common bile duct occurred in one third of the ex-
Downloaded by: Universite Laval. Copyrighted material.
Endoscopy 9 (1977) 95-98 0 Georg Thieme Verlag, Stuttgart
96
H. Koch, M. Stolte, V. W alz
Fig. 1
Fig. 2
Lithotripsy-probe with Dormia basket.
perimental animals. Additional experiments confirmed the suspicion that the perforations were not caused by the pressure wave produced by the lithotripsy probe, but by fragments of the "exploding" stone. For this reason, the lithotripsy probe was combined with a Dormia basket, in which the calculi can be grasped and retained, also during smashing.
Method and Patients Electrohydraulic lithotripsy is based on the principle that spark discharges in a liquid me-
dium give rise to steep hydraulic pressure waves. These waves are of such high energy that they can smash stones into fragments. Lithotripsy probe: the most important part of the lithotripsy probe is the spark chamber which is open to the front. It contains two rod
electrodes. Into the inside of the probe, in addition to the electric leads for the rod elec-
trodes, a further channel opens, into which liquid can be sprayed from outside. This liquid
is necessary for the production of the pressure wave. The sparkover is trigered and controlled
by a surge current generator (the Lithotron, manufactured by the firm of Walz, 7271 Rohrdorf) (Fig. 1). In the tip of the lithotripsy probe, a Dormia basket has been integrated. The four "arms" of the basket, embrace the spark cham-
ber from the outside and, in this way, enable the calculus to be drawn centrally up to the opening in the tip of the probe and fixed there. To permit the introduction of the probe, the
external diameter of which is 2.7 mm, the basket can be completely withdrawn (Fig. 2).
With this probe, initial attempts at destroying stones were carried out in the common bile ducts of 20 corpses.
Following theses experiments, electrohydraulic lithotripsy was then attempted in three patients in whom stones in the common bile duct were so large that they could not be extracted even after extensive papillotomy.
Downloaded by: Universite Laval. Copyrighted material.
Generator Lithotron.
Endoscopic Lithotripsy in the Common Bile Duct
97
Fig. 4 Stone crushed with electro-
hydraulic lithotripsy.
In the case of all three patients, the common bile duct was first filled, retrograde, with con-
the probe channel. Finally, the spark discharges were triggered (Fig. 4).
trast medium to facilitate the localization of the stones. Then, the lithotripsy probe was introduced. On account of the large diameter
Results
of the probe, an endoscope with an adequately wide-lumened instrument channel was necessary. To satisfy this requirement, the GFB-2 long endoscope manufactured by Olympus, Hamburg, was employed. After introducing the probe into the common bile duct, the Dor-
mia basket was advanced, the stone "captured" and then drawn up against the tip of the probe (Fig. 3). Then, to enable particularly
powerful pressure waves to be produced, a hypertonic liquid made up of 300/o glucose and physiological saline solution, was instilled via
In the experiments on corpses, all the calculi introduced into the bile duct were smashed. No lesions occurred in the bile duct. In all three patients, it was possible to break
fragments of the calculi. Subsequent stone extraction, however, was possible in only a single case (Figs. 5 and 6). No complications were observed. Discussion The experimental studies in the corpses have
shown that the lithotripsy probe combined with a Dormia basket permits the destruction
Downloaded by: Universite Laval. Copyrighted material.
Fig. 3 Stone catched in lithotripsy probe.
H. Koch et al.: Endoscopic Lithotripsy in the Common Bile Duct
Fig. 5 Stone catched in lithotripsy probe.
Fig. 6 Fragmented stone.
of stones. Initial attempts to employ this
reliably captured and held centrally. Appropriate efforts are presently being made. Such
method in the living patient only partly confirmed the results with corpses. Thus, to date, in clinical application, it has proved possible only to break small fragments off the stones. In these cases, this lack of success has clearly been due to the inability to capture the calculi with the Dormia basket in such a way that they
can be located centrally in front of the opening of the lithotripsy probe. The X-ray pictures obtained during the attempts to destroy the stones clearly indicate that the latter were located in the basket in such a way that the tip
of the lithotripsy probe was directed more tangentially to the margin of the calculus. In all the cases, despite repeated attempts, it was not possible to position the calculi centrally in the basket. The consequence of this is that the Dormia basket of the lithotripsy probe must be improved to ensure that the stones can be
efforts appear justified since it has been shown that even with a less than optimal position of the lithotripsy probe in the bile duct, no complications have occurred and that, despite the problems, one calculus was reduced in size to such an extent that its extraction became possible. An additional points is that, to date, no other method for the removal of large
bile duct calculi with a tolerable expenditure of time and effort has been developed. References Jvancevic, L.: Die elektrohydraulische Lithotripsie. Dtsch. med. Wschr. 96 (1971) 485
Koch, H., D. Belohlavek, M. Stolle, M. Clamen, V. Becker: Papillotomie und Steintherapie im Gallengang - Klinische Erfahrungen. In: R. Ottenjann, Fortschritte der Endoskopie. Schattauer, Stuttgart 1975 Koch, H., D. Belohlavek, O. Schaffner, M. Stolle, V. Walz: Lithotripsie im Choledochus. In: W. Rösch, Fortschritte der Endoskopie. Verlag Dr. Sträube, Erlangen 1976
Reuter, H.-J.: Electric treatment of bladder stones. Endoscopy 1 (199) 13
Priv.-Do:. H. Koch, Med. Univ.-Klinik, 8520 Erlangen, Dr. M. Stolle, Path. Inst. d. Univ., 8520 Erlangen Dipl.-Ing. V. Walz, Walddorfer Str 40, 7271 Rohrdorf
Downloaded by: Universite Laval. Copyrighted material.
98
