Robert

K. Feldman,

Pancreatic Treatment

MD

#{149} Patrick

and with

Percutaneous tunable dye laser lithotripsy was used in two patients to successfully fragment a 2-cm left hepatic duct calculus and a 5-mm main pancreatic duct calculus. Tanable dye laser lithotnipsy may prove to be a more effective alternative to mechanical lithotripsy. Index ducts, ducts,

terms: Bile ducts, calculi, 76.28 #{149} Bile interventional procedure, 76.1228 #{149} Bile stone extraction, 76.1228 #{149} Lasers. Lithotripsy #{149} Liver, calculi, 765.28 #{149} Pancreas, interventional procedure, 770.1228 #{149} Pancreatic ducts, 770.28

Radiology

1990;

174:793-795

C. Freeny,

Biliary Tunable

I

#{149} Richard

A. Kozarek,

stones of gallbladder origin are relatively rare. Untreated, however, they remain a persistent problem. The clinical presentation varies from that of acute cholangitis to an indolent course of pain, jauntdice, and repeated episodes of cholangitis. Therapy is directed at eliminating the source of the calculi (ie, cholecystectomy) and extracting the intrahepatic stones. Surgical therapy for intrahepatic calculi consists of lithotomy

for

limited

MD

Calculi: Percutaneous Dye Laser Lithotripsy’

NTRAHEPATIC

disease

or hepatic

resection for extensive lobar involvement. Intrahepatic stones may also be extracted

1 From the Departments of Radiology (R.K.F., P.C.F.) and Gastroenterology (R.A.K.), Virginia Mason Clinic, 1 100 Ninth Ave. P0 Box 900, Seattle, WA 98111. Received July 25, 1989; revision requested August 29; revision received October 26; accepted October 31 . Address reprint requests to R.K.F. (C RSNA, 1990

MD

endoscopically

or percuta-

pulse numbers utilized were based on in vitro gallstone data (1,2) and unpublished work on pancreatic stones. CASE Case 1.-A ic relapsing underwent

pulses

at a repetition

second quartz

and is delivered fiber. The joule

rate

of 1-20

per

via a 250-sm setting and

extraction

hepatic

seg-

of sludge

and

the left intrahepatic

from

Cholangiography

ducts.

performed

5 months

later via a surgically placed biliary drainage catheter demonstrated a residual 2-cm left hepatic duct calculus (Fig 1). A percutaneous transhepatic right hepatic duct catheter was placed for subsequent stone extraction. With use of standard aseptic technique and fluoroscopic guidance, the left hepatic duct calculus was captured with a stone basket via the transhepatic catheter track. A 250-sm

control

duct. The laser used was a bench model manufactured by Candela (Boston). It utilizes coumanin green dye that emits a wavelength of 504 nm. Energy is transmitted in 1.2-asec

lateral

calculi

intrahepatic

pancreatic

left

and

September

and

partial

man with chronand cholangitis

mentectomy

neously via a direct transhepatic approach or via a surgically placed T tube at the time of cholecystectomy. Large intrahepatic calculi are not readily extracted by any means. A large calculus must first be crushed with a stone basket and the fragments extracted or irrigated from the duct. A large stone that is captured and not crushed poses serious problems if it cannot be released from the basket. Tunable dye lasers have been utilized to fracture stones in the ureter and common bile duct in vivo and gallstones in vitro (1-8). These lasers are thought to effect fragmentation by laser light absorption onto the stone surface. The light may initiate a plasma (a gaseous collection of ions) on the stone surface that can rapidly expand and collapse, initiating a mechanical shock wave (8,9). Two cases are presented to demonstrate the feasibility of percutaneous tunable dye laser lithotripsy in the ducts

REPORTS

66-year-old biliary colic

quartz

fiber

and

a 0.025-inch

Tracker

catheter (Target Therapeutics, San Jose, Calif) were passed into the center lumen of the basket catheter, and 500 pulses of 60 mJ each were applied to the stone, with subsequent fragmentation (Fig 2). The fragments were irrigated from the left duct. However, repeat cholangiography the following day showed three small remaining fragments, which were extracted from the left duct with a stone basket without difficulty. Repeat cholangiography

48 hours

tion showed (Fig 3). The moved and the hospital. problems at 6 months. Case 2.-A

coholic

after

laser

fragmenta-

no residual calculi or debris transhepatic catheter was repatient was discharged from The patient had no further follow-up examination after 57-year-old

woman

with

a!-

chronic calcific pancreatitis untwo partial pancreatectomies and pancreatic duct stone extraction in

denwent

main

1985

of pain.

and

November

A residual

1988

5-mm

for

obstruct-

ing main pancreatic duct calculus necessitated surgical placement of a percutaneous

pancreatostomy

drainage

catheter

af-

ter the laparotomy in November 1988 (Fig 4). In January 1989 the patient was readmitted

tion. scopic

for percutaneous

Under control,

can Cystoscope

direct

stone

fluoroscopic

an 8-F miniscope

Makers

fragmenta-

and endo(Amen-

Inc [ACM!], 793

--5M1 ,....

.

.

.

2.

1.

3.

Figures 1-3. Case 1. (1) Cholangiogram obtained with use of a surgically hepatic duct. (2) Close-up of stone basket with 250-tim quartz lithotnipsy via the center lumen. The radiopaque platinum tip of the catheter (long (3) Cholangiogram obtained after laser fragmentation and percutaneous culi or debris. Persistent left duct dilatation from central stricture (arrow)

4.

placed drainage catheter shows a 2-cm calculus (arrows) in the left fiber (short arrow) and 0.025-inch catheter passed into the basket arrow) assisted in placement of the nonradiopaque laser fiber. stone basket extraction of residual fragments shows no residual calis present.

5.

Figures

Case

4, 5.

obtained after partial pancreatectomy shows changes of chronic pancreatitis, a 5-mm stone (solid arrows) at the genu, and a tight main pancreatic duct stricture (open arrow). (5) Radiograph of an 8-F ACMI miniscope (solid anrow) and safety guide wire (open arrow) passed through the pancreatic duct catheter track. The stone and quartz lithotnipsy fiber are not radiopaque. The stone was visualized through

the miniscope

2.

(4) Pancreatogram

during

lithotnipsy.

Boston)

(10) was passed through the pancreatic to the impacted calculus. fiber was passed directly opsy

channel

posed

of the

directly

miniscope

to the

den videoendoscopic of 40 mJ each

stone

(Figs

moved,

were

antegnadely duct catheter track A 250-tim quartz through the biand

stone

control;

250 pulses

then

applied

5, 6). The miniscope

and

a 5-F 7-cm

stent

was then

duct

with

distal

un-

to the duct

in the pancreatic end

in the duode-

num. The pancreaticocutaneous fistula closed in 48 hours, and the patient has remained symptom up. Endoscopic

free at 6-month pancreatography

1989

showed

no

recurrent

stent

was removed.

followin May

calculi,

and

the

cases demonstrate of tunable dye

the management pancreatic duct plying

this

of the 794

.

the lithotnipsy

duct

quartz Radiology

use-

of intrahepatic calculi. However, is difficult.

application

wall

requires

passage

fiber

through

a stone

for

platinum laser

lithotripsy.

The

tip of the fiber contact

fiber end

cathewith

onto

the

by

access

captured of

this

calculi to

the

in

miniscope

with

and ap-

working

lumen

is limited pancreatic

(Baxter,

undergoing

vestigation

at our

may

facilitate

to A 7-F

clinical institution

pancreatic

Additionally, are nonobstructing

medical,

have

vi-

used

to

guidance

worked.

imaging

Al-

modalities

posed no difficulty at this institution, this could prove problematic elsewhere. Control of this technology be

determined

scopic

in

delivery

part

by

system

vs percutaneous)

and

(videoendoscopic

the

(endo-

imaging vs fluoro-

scopic).

in-

The

inter-

majority and can

sharing

modality

and

duct the

either

potentially

though

be

all

were

lithotripsy,

would

well

in which

control

therapeutic

central Irvine, Calif)

may

and surgical alternatives exhausted. both fluoroscopic and

deoendoscopic

may

primarily duct.

a 0.025-inch

is currently

vention. calculi

stone.

endoscopic, have been Although facilitate

Application

stones

to cases

obtained no resid-

shows

endoscopically.

pancreatic

limited

was inof the

technology

managed for

catheter but no further, and the length was marked with sterile tape on the fiber 2 cm proximal to the catheter entry site. The catheter and laser fiber were advanced through the center lumen of the stone basket and the laser fiber safely apposed di-

pancreatic

inadvertent

the

contact

Application

technology

Preventing onto

stone

radiopaque ten facilitated

nectly

DISCUSSION These fulness

firm

the biliary stone. The serted to the radiopaque

was ne-

pancreatic

placed

the

ap-

pancreatic

basket that has captured the stone or use of direct vision through a miniscope. Furthermore, the fiber is not radiopaque, so it is difficult to con-

Figure 6. Case 2. Pancreatogram after tunable dye lithotripsy ual calculi or debris.

of be

in vitro

use

cases,

however,

imply

widespread

technology. technique

and

do

clinical

necessarily

application

One into

cited

not has

the

to

place

of this this

perspective

of

March

1990

multiple competing technologies: biliany and pancreatic stent placement, surgery, mechanical lithotnipsy, yttrium-aluminum-garnet (YAG) laser lithotnipsy (1 1), extracorporeal shock wave lithotripsy (12,13), electrohydraulic lithotripsy (14), ultrasonic lithotripsy, and various dissolution agents. Additionally, the expense of the equipment (approximately $240,000 for a coumanin green tunable dye laser) may limit application to treatment centers only. U

3.

4.

5.

6.

7.

References 1.

2.

Faulkner DJ, Kozarek RA. Gallstones: fragmentation with tunable dye laser and dissolution with methyl tert-butyl ether in vitro. Radiology 1989; 170:185-189. Kozarek PA, Low DE, Bull TJ. Tunable dye laser lithotnipsy: in vitro studies and in vivo treatment of choledocholithiasis. Gastrointest Endosc 1988; 34:418-421.

Volume

174

#{149} Number

3

8.

9.

Watson GM, Jacques SL, Dretter SP, Parrish JA. Tunable pulsed dye laser for fragmentation of ureteral calculi. Lasers Sung Med 1985; 5:160. Watson GM, Murray S, Dretler SP, Parrish JA. An assessment of the pulsed dye laser for fragmenting calculi in the pig ureter. Urol 1987; 138:199-202. Watson GM, Murray S, Dretler SP, Parrish JA. The pulsed dye laser for fragmenting urinary calculi. J Urol 1987; 138:195-198. Dretler SP, Watson GM, Parrish JA, Murray S. Pulsed dye laser fragmentation of ureteral calculi: initial clinical experience. J Urol 1987; 137:386-389. Nishioka NS, Levins PC, Murray SC, et al. Fragmentation of biliary calculi with tunable dye lasers. Gastroenterology 1987; 93:250-255. Teng P, Nishioka NS, Anderson RR, Deutsch TF. Acoustic studies of the role of immersion in plasma-mediated laser ablation. IEEE J Quant Electrophysiol 1987; QE-23:1845-.1852. Nishioka NS, Teng P, Deutsch iT, Anderson RR. Mechanism of laser-induced fragmentation of urinary and biliary calculi. Lasers Life Sci 1987; 1:231-245.

10.

11.

12.

13.

14.

Kozarek RA, ed. Miniscopes: a technology in search of an application. J Clin Gastroenterol 1988; 10:475-478. Ell Ch, Lax C, HochbergerJ, Muller D, Demling L. Laser lithotripsy of common bile duct stones. Gut 1988; 29:746-751. Martin LG, Ambrose SS, Bias DL, Amerson JR. Extracorporeal shock wave lithotipsy of intrahepatic stones: case presentation and review of the literature. Am Surg 1988; 54:311-314. Vorwerk D, Gunther RW, Fischer N, Thon HJ. Combined treatment of stone-obstructed hepatico-jejunostomy with interventional techniques and ESWL. Cardiovasc Intervent Radiol 1988; 11:72-74. LearJL, Ring EA, Macoviak JA, Baum S. Percutaneous transhepatic electrohydraulic lithotnipsy. Radiology 1984; 150:589590.

Radiology

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