Indian J Gastroenterol (May–June 2014) 33(3):237–240 DOI 10.1007/s12664-013-0412-4

ORIGINAL ARTICLE

Short-term biliary stenting before mechanical lithotripsy for difficult bile duct stones Shyam Sundar Sharma & Ashok Jhajharia & Sudhir Maharshi

Received: 7 June 2013 / Accepted: 9 September 2013 / Published online: 6 December 2013 # Indian Society of Gastroenterology 2013

Abstract Background and Study Aim Short-term common bile duct stenting has been shown to decrease stone size, but its effect on mechanical lithotripsy has not been reported. Patients and Methods Sixty patients of difficult bile duct stones were subjected to mechanical lithotripsy. Thirty patients were subjected to mechanical lithotripsy at the time of first endoscopic retrograde cholangiopancreatography (group A) while another 30 patients were subjected to mechanical lithotripsy using trapezoid basket after a short period of stenting (group B). The effect on the hardness of stone, durability of the basket after stenting, and duration of mechanical lithotripsy was studied. Results Lithotripsy after stenting was less time consuming, and durability of the basket was much more in comparison to lithotripsy without stenting (p 0.05). Thirty-two patients were not included in the study because of more than three large or single large stone not allowing basket to open around stone (n =11), patient not coming for follow up after stenting (n =7), patients not willing for second ERCP as they were asymptomatic (n = 5) spontaneous passage of stone (n =2), patients refused for participating in study (n =2), and CBD clearance could be achieved without lithotripsy (n =5). In group A, mechanical lithotripsy was done at the time of first ERCP. Mean diameter of stone in this group was 17.86 mm. There were 20 males and 10 females in this group. Mean age of the patients was 45.93±(12.43) years (25 to 75 years). A total of 18 baskets were required to clear the

Indian J Gastroenterol (May–June 2014) 33(3):237–240

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CBD in 30 patients of group A. None of the patients’ stones could be crushed manually without the need of handle. In two patients, wires of the two baskets were broken even with single use though CBD could be cleared. In group B, more than one difficult stone or single difficult stone were subjected to initial stenting and patients were asked to come after 2 to 3 months for final removal of stone and stent. There were 19 males and 11 females, mean age was 46.8 years (20 to 80 years). Most of these patients came late, and median duration of stenting was 3.5 months. Mean diameter of stone before stenting was 18.0 mm. Stone size decreased marginally in 17 patients; mean diameter remained unchanged in 10 patients. In three patients, in addition to original large CBD stone, CBD was full of sludge and multiple small stones. In post-stenting group, six patients had two stones, one patient had three stones, and 23 patients had single difficult stone. In 12 patients, in post-stenting group, stones could be crushed with manual force and lithotripsy handle was not needed. In the remaining 18 patients, stones required crushing with handle. A total of four baskets were sufficient to clear CBD in 30 patients, which included six patients with two stones and one patient with three stones. In 30 patients, where mechanical lithotripsy was done without stenting (group A), the mean (SD) procedure time (mechanical lithotripsy+CBD clearance) was 57.8 (13.2) min while it was 34 (11.9) min in group B; the time taken in cannulation, sphincterotomy, biliary stenting, and stent removal was not calculated in the latter group. Difference in procedure time between the groups, calculated as above, was statistically significant (p 90 % of patients [8]. It was not clear from that study how many patients required mechanical lithotripsy and what was the effect of stenting on the outcome of mechanical lithotripsy. Optimal duration of stenting to decrease stone size is not exactly known, but 2 to 5 months is usually suggested and duration greater than this will not decrease stone size. In the present study, the patients were asked to come for lithotripsy after 2 to 3 months of stenting but most of the patients were asymptomatic and came late. The median duration of stenting in the present study was 3.5 months. There was definite decrease in hardness of stones as only four baskets were required to clear stones in 30 patients after stenting while 18 baskets were required to clear stones in 30 patients of group A. Decrease in hardness of stones was also evident by the fact that in post-stenting group in 12 patients, stones could be broken with manual force and handle was not needed, while in all patients without stenting, handle was required to crush the stones. Complications were seen only at the time of initial procedure, and only two patients who came 5 months after initial stenting presented with cholangitis. This was possible due to addition of sphincterotomy to stenting which allowed bile flow even after stent block. No study prior to this studied the effect of stenting on outcome of lithotripsy. After stenting, mechanical lithotripsy was easy, requiring less time to clear the CBD, less number of baskets was required, and stones became softer, so it was easy to break them. Requirement of less number of baskets to clear the CBD in more patients was a clear advantage of stenting. We definitely feel that sphincterotomy and short 2 to 3 months stenting should be done to all patients with large stone before subjecting them to mechanical lithotripsy to make the procedure easy and less time consuming.

240 Conflict of interest The authors do not have any conflicts of interest to declare.

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Indian J Gastroenterol (May–June 2014) 33(3):237–240 5. Binmoeller KF, Bruckner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy. 1993;25:201– 6. 6. Sauerbruch T, Holl J, Sackmann M, Paumgartner G. Fragmentation of bile duct stones by extracorporeal shock wave lithotripsy: a five year experience. Hepatology. 1992;15:208–14. 7. Neuhaus H, Hoffmann W, Gottlieb K, Classen M. Endoscopic lithotripsy of bile duct stones using a new laser with automatic stone recognition. Gastrointest Endosc. 1994;40:708–15. 8. Akira H, Yoshiko N, Masashi K, et al. Biliary stenting in the management of large or multiple common bile duct stones. Gastrointest Endosc. 2010;71:1200–3. 9. Fan Z, Hawes R, Lawrence C, Zhang X, Zhang X, Lv W. Analysis of plastic stents in the treatment of large common bile duct stones in 45 patients. Dig Endos. 2010;23:86–90. 10. Akcakaya A, Ozkan OV, Bas G, et al. Mechanical lithotripsy and/ or stenting in management of difficult common bile duct stones. Hepatobiliary Pancreat Dis Int. 2009;8:524–8.

Short-term biliary stenting before mechanical lithotripsy for difficult bile duct stones.

Short-term common bile duct stenting has been shown to decrease stone size, but its effect on mechanical lithotripsy has not been reported...
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