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775
The Value of Extracorporeal Shock-Wave Lithotripsy in the Management of Bile Duct Stones
Stephen H. Le& J. Stephen Fache H. Joachim Burhenne
We evaluated the role of biliary extracorporeal shock-wave lithotripsy in treating 70 symptomatic patients with bile duct stones in whom endoscopic or percutaneous radiologic attempts at basket extraction had failed. Forty-four patients had common bile and/or
common
patients
hepatic
duct
had intrahepatic
elimination
of stone
stones,
fragments
stones were successfully
21 patients
duct stones. during
fragmented
had
cystic
duct
A total of 43 patients the initial
treatment
period.
yet not totally eliminated
stones,
(61%)
and
five
had complete
If patients
in whom
on initial hospital treat-
ment but who were asymptomatic at follow-up times of 8-22 months are included, the overall successful treatment rate was 83%. Stones were cleared in 26 of 44 common bile/hepatic duct stone patients, spontaneously in seven patients and after endoscopic or percutaneous radiologic intervention in 19 patients. Fifteen (71%) of 21 patients had cystic duct stones successfully cleared. The fragments in two of five patients with
intrahepatic
duct stones also were cleared.
Five patients
(7%) had minor side effects.
(10%) of 70 patients went on to have surgery. Complications after 30 days occurred in five patients (7%); two required repeated endoscopy with fragment extraction, two required placement of an endoprosthesis, and one died. We conclude that biliary extracorporeal shock-wave Iithotnpsy is valuable as an adjuvant to standard interventional techniques for removing bile duct stones. Seven
AJR 155:775-779,
October
1990
Biliary extracorporeal shock-wave method for treating bile duct stones
lithotripsy when other
(BESWL) is now a recognized methods have failed, and it has a
reported success rate of up to 93% [1-4]. The mainstay for treating bile duct stones is endoscopic retrograde cholangiography (ERG) and sphincterotomy with stone extraction, which in experienced hands has a successful stone clearance rate of around 90% [5]. If a T-tube is in place, then the radiologic means of stone extraction via the T-tube tract has a greater success rate (95%) for duct clearance with lower preliminary
morbidity experience
and mortality with BESWL
stones with a first-generation in the treatment
second-generation,
Received March 1 9, 1 990; accepted after revision May 7, 1990. I All authors: Department of Radiology, University of British Columbia and Vancouver Hospital, 855 W. 12th Ave., Vancouver, ada vsz i M9. Address reprint requests Burhenne.
0361-803X/90/1 554-0775 0 American Roentgen Ray Society
General BC, Canto H. J.
Subjects
lithotripter
of an additional
bathless
rates [6]. We have previously reported in treating both common duct and cystic
[7]. We now describe
62 patients
with
our duct
the value of BESWL
bile duct
stones
by using
a
lithotripter.
and Methods
Between October 1987 and October 1989, 70 symptomatic patients with bile duct stones were treated with BESWL after failure of radiologic or endoscopic attempts to remove some or all of these
stones
with
standard
basket
extraction
techniques.
All
radiologic
procedures
were performed in our institution, whereas ERC was performed by several different clinicians, and approximately one third of the ERC procedures were performed in outside institutions. Of the 70 patients, 46 had common bile duct (CBD) and/or common hepatic duct (CHD) stones, 21 patients had cystic duct (CD) stones, and five patients had intrahepatic duct (IHD)
LEE
776
stones. One patient had both CBD and CD stones treated, and one other patient had both CBD and IHD stones treated. The first eight patients were treated on a Dornier HM-3 lithotripter
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(Munich,
West
subsequent 62 Erlangen, West electrical nerve patients (16%), 62
patients
stones
Germany),
and
all required
epidural
anesthesia.
and
targeted
epidural
anesthesia
with
the
Lithostar
prone
position
in the
in one Plus, by
patient
(2%).
patients
58 using
overhead,
had
There
with IHD stones.
were
36
men
and
34
women,
years (mean, 71 .5 years). Previous formed in 41 (59%) of 70 patients. CD stones
had
an in situ
other
six
cholecystectomy. stones,
stones, ranged
Fifteen
gallbladder,
had had cholecystostomy The
with
range
of 21
high-risk
for acute
primary one
The
and Method
Opacification
Route
T-tube
Note.-CBD = common bile duct; cystic duct; IHD = intrahepatic duct. “ Includes one calcified stone that
disease.
0
1
10 0 8 1
2 1 2”
2 0
targeting. b All five
patients
had
retained
stones
did after
=
not
require
contrast
cholecystectomy.
three
with
disease,
and
recurrent one
with
was diagnosed
in
the
method
of targeting
catheters
(ES) were
are
catheters at the
placed
shown
in place all time
above
of failed the calculi
routinely.
In the treatment
of CBD/CHD
stones,
was
for
CD
(mean, 571 2). The average
1 3,655
1 .71 (range,
the
number
of shocks
(mean, 7254). The average was 2.26 (range, 1-7). stones
ranged
number
from
of treatment
given
number
of
1 231
to
sessions
1-4).
The number of shocks given to the five patients with IHD stones ranged from 551 3 to 9000 (mean, 7504). The average number of treatment sessions was one to four (mean, 2.4). No more than 4000 were interval
administered
in each
of 48 hr between
or contact
dissolution
treatment
sessions. agents
session, No oral
were
with
adjuvant
a minimum chemolith-
used.
Results
1
2 hepatic
none
was 2.5
IHD
5b
common
and
whenever possible. Percutaneous transhepatic catheters were inserted in 10 patients, eight of whom had prior ERG, with ES performed in five. Patients with cholangitis underwent lithotripsy after a period of biliary catheter drainage and appropriate antibiotic therapy. Patients who had no clinical evidence of infection were not given
time
of Targeting
Caroli
sphincterotomy
1). The
treatment sessions required The number of shocks given
CD
CHD
and
endoscopic (Fig.
disease:
with
who had nasobiliary
who
gallbladder
stones,
size treated
1990
cholecystectomy.
patients
25
Sonography
after
of opacification
extraction
solitary
stone
Mirizzi syndrome
ranged from 700 to 26,000
CBD and CHD
catheter
biliary one
Those patients
1.
undergone
stone
underlying
cholangitis.
patient
route
in Table
olysis
Nasobiliary catheter Transhepatic catheter Cholecystostomy catheter
had
scierosing
other
had
October
1 .1 7 cm).
with
retained
Route
16 (76%)
The maximum
cholangiohepatitis,
shocks 1: Opacification
patients,
patients
eight had two stones, six had three stones, four had four and 1 7 had five or more stones. Maximal stone diameter from 0.8 to 3.5 cm (mean, 2.13 cm).
TABLE
size,
antibiotics
of 29-99
CD
patients
pyogenic
had been per-
CD stump stones missed at CBD, CHD, and IHD patients, 16 had solitary
had
Of the
(71%)
all were
performed
patients
an age
cholecystectomy
21
cm (mean
had
biplanar
CD stones, one patient with a large CHD stone, and
impacted
one patient
the
Five
fluoroscopy with prior bile duct opacification. Fluoroscopy time ranged from 1 .1 to 1 1 .3 mm (mean, 5.3 mm). Stones in the other four patients were targeted sonographically with the patient supine by using the overhead module. These four patients included two patients with
Of
Of the
(94%)
AJR:155,
had more than two stones.
The
patients were treated on a Lithostar Plus (Siemens, Germany), with IV analgesia and/or transcutaneous stimulation in 51 patients (84%), no analgesia in 10
treated
ET AL.
duct; material
CD
=
for
Twenty-six (59%) of 44 patients with CBD/CHD stones were discharged from the hospital clear of fragments and stones. Of these 26 patients, seven passed fragments spontaneously as confirmed by follow-up cholangiography; five of the seven had had ES performed and the other two patients had T-tube tracts. The remaining 1 9 patients required adjuvant techniques to clear the bile ducts (Table 2). This included
Fig. 1.-A, Digital fluoroscopic image during targeting of 20-mm stone in common bile duct
with contrast
material
injected
via nasobiliary
catheter. Total of 3500 shocks were administered to largest stone and 1000 shocks to smaller stones in common hepatic duct. B, Nasobiliary cholangiogram 24 hr later reveals multiple stone fragments less than 5 mm in diameter.
A
B
ESWL
AJR:1 55, October1990
TABLE
2: Method
No. of Patients Cleared (%)
Site
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CBD/CHD CD IHD
a
=
=
endoscopic
Includes
Clearance
ERC
26/44 (59%) 15/21 (71%) 2/5 (40%)
Note.-CBD EAC
of Fragment
OF BILE
After
T-Tube Extraction
who required
STONES
777
Lithotripsy
Transhepatic Extraction
Transcholecystostomy Extraction
Spontaneous
12
5
2
0
7
1
1
0
9
4
1
0
1
0
0
common bile duct; CHD = common retrograde cholangiography.
one patient
DUCT
adjuvant
hepatic duct; CD
intracorporeal
1 2 patients with ES who underwent ERC on up to three separate occasions. One patient required balloon dilatation of a common hepatic duct stricture in order to completely clear the ducts of fragments (Fig. 2). Of the remaining 18 patients in whom the ducts could not be cleared with BESWL and adjuvant techniques, 1 5 had fragments smaller than 5 mm. The other three patients required surgery to clear the ducts, one because of a large 18mm stone refractory to treatment despite receiving 10,464 shocks during three treatment sessions, one because of recurrent pain from persisting fragments, and one because
cystic
=
electrohydraulic
duct;
IHD
=
intrahepatic
duct;
Iithotnpsy.
whether this patient has residual or recurrent stones in the biliary tree. When those patients in whom fragments were successfully
cleared at the initial time of treatment (26) are compared with those in whom the ducts did not clear (1 8), the difference
pancreatitis developed and the patient underwent cholecystectomy and bile duct clearance. The last two patients had
between the age groups is statistically significant. Patients who were treated successfully were younger (mean age, 66 years) than the patients in whom treatment failed (mean age, 75 years) (Wilcoxson Rank Sum Test, p = .0289). There was a tendency to use more shocks in the older group that was significant only at the 1 0% level (p = .835). No statistically significant difference was seen in stone size or stone number between the two groups (p = .1 707 and .1 41 6, respectively).
persistent Of the
Of the 21 patients with cystic duct stones, 1 5 (71 %) had stones and fragments cleared after a maximum of two litho-
fragments larger than 5 mm. 1 5 patients with retained fragments,
1 0 remain
asymptomatic with follow-up times of between 2 and 26 months (mean, 1 1 .9 months); all 10 had fragments smaller than 5 mm. Recurrent cholangitis developed in three patients and pancreatitis in one; all four had further ERC performed during which two patients had their ducts cleared and two had an endoprosthesis inserted because of failure to extract all residual stone fragments. The final patient had recurrent episodes of painless jaundice assumed to be due to his
underlying
primary
sclerosing
cholangitis.
Fig. 2.-A, T-tube cholangiogram shows two calculi in common hepatic duct(CHD)Iying proximal to a stricture right hepatic duct. B, cholangiogram
in CHD
and
obtained
one
calculus
24 hr after
in
litho-
tipsy shows successful fragmentation after 3021 shocks were targeted to all three stones.
It is not known
tripsy treatment sessions. with in situ gallbladders,
This eight
occluded
was
ment.
cystic
Eleven
duct
that
of the 1 5 patients
group included of whom had rendered
required
1 2 patients a previously
patent
further
after
treat-
percutaneous
extraction of stone fragments to clear the biliary tree. In four cases, fragments passed spontaneously most probably via the gallbladder
and cholecystostomy
tract
(Table
2). Of the
six patients in whom the cystic ducts were not adequately cleared, the three patients with in situ cholecystostomy cath-
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778
LEE
ET AL.
AJR:155,
October1990
eters went on to have cholecystectomy. The other three patients had retained cystic duct stump stones and are asymptomatic with a follow-up time of between 5 and 23 months. When the successfully treated CD stone group (n = 15) was compared with the unsuccessfully treated group (n = 6), the difference between the stone sizes, stone numbers, and number of shocks used was not statistically significant (Wil-
with conventional baskets [1 0], rotational catheters [1 1], ultrasonic contact lithotripsy [1 2], electrohydraulic lithotripsy [13, 14] and laser lithotripsy with a pulsed tunable dye [15], a continuous wave Nd-YAG laser, or a copper vapor laser
coxson Rank Sum Test, p = .929, .1 719, and .61 23, respectively). Of the five patients with IHD stones, two patients had their
that no strong evidence favoring any one of these techniques is available. In those cases in which suitable expertise is not
biliary tree cleared; both required adjuvant treatment, one via the transhepatic route and one via the endoscopic route (Table
2). Three
patients
the three were known hepatitis
and
remain
had partial
stone
to have recurrent asymptomatic
clearance;
pyogenic
at follow-up
two of
cholangiotimes
of 8
[16]. Some authors various methods tion, albeit
claim success rates of up to 100% for the of bile duct stone fragmentation and extrac-
in small selected
series
many of these cases of recurrent
are compatible with Caroli intrahepatic biliary radicle.
treatment
within
a large
dilated
Stones in six (9%) of 70 patients did not show evidence of fragmentation. This included two patients with CBD stones, one of whom required surgery and one of whom required insertion of an endoprosthesis. The other four cases were managed expectantly. In all 70 patients, recorded side effects were few; fever developed
in three
in one patient, were
treated
patients
patients,
and hemobilia conservatively
asymptomatic
hyperamylasemia
in one patient. without
All five patients
further
morbidity.
died after 30 days. One 90-year-old
weeks
after
lithotripsy
treatment.
This
woman
patient
We
initially
reported
our
stones occur.
with
BESWL
in the
and four cases of
cystic duct stones with the Dornier HM-3 lithotripter [7]. We have now treated another 62 patients with a Siemens Lithostar Plus lithotripter, which includes an overhead module for sonographic
targeting
and
produces
shock
of higher
waves
energy than the fluoroscopically targeted undercouch shock head. However, in only four patients were the stones adequately visualized with sonography to enable the use of the overhead module. The major route of cystic duct opacification
for targeting
was via a cholecystostomy
a mini-cholecystostomy
died 7
risk patients
who present
1 8]. Through
this tract,
cholangitis and septicemia in which satisfactory biliary drainage was not achieved despite successful fragmentation and repeated attempts to clear the ducts at ERC in an outside institution. The other two deaths were in patients aged 85 and 95 who were discovered on follow-up ERG to have malignant bile duct strictures that were satisfactorily stented, but both died approximately 2 months after stent insertion.
or retained
experience
of four cases of bile duct stones
Three
had recurrent
data suggest
available or stones are not removed, BESWL has proved to be extremely valuable in fragmenting intrahepatic, bile duct, and cystic duct stones such that fragments either pass spontaneously or can easily be removed by adjuvant techniques. Few cases should require surgery with its attendant risks, especially in the elderly and high-risk age groups in which
and 22 months. The third patient also remains asymptomatic despite retained stone fragments, the appearances of which disease,
[1 4]. Current
under
for both bile drainage By treating have been
patients
tract, as we perform
local anesthetic
access
is gained
manner,
high-
disease
[17,
to the gallbladder
and early radiologic in this
stone
extraction.
morbidity
significantly reduced without BESWL has a significant
cystectomy.
in those
with acute gallbladder
and mortality the need for chole-
role to play in the
management of impacted cystic duct stones when percutaneous extraction has failed. Treatment can be performed either during the same hospital admission, within 5-1 0 days
of cholecystostomy, or on an outpatient basis. In either situation, symptoms and signs of acute gallbladder inflammation should have resolved before treatment with BESWL. Discussion
Our overall
There are several nonsurgical means of treating bile duct stones, of which ES with stone extraction is the most widely used. If a postoperative T-tube is in place, then percutaneous radiologic
stone
should
extraction
be the method
morbidity
with
of choice
and zero mortality
the
Burhenne
because
technique
of its much lower
rate [6].
success
rate for fragment
lithotripsy
[1 9]. There are several possible explanations.
First,
in our patients we do not pursue fragments smaller than 5 mm that remain within the bile ducts of patients who have
had adequate
sphincterotomies.
These
expectantly
in excess
are notoriously
than 5 mm in size, 1 0 remain asymptomatic
to remove by mented before eral means are use of contact ether (MTBE) tripsy
taneous
difficult
any nonsurgical route and have to be fragpercutaneous or endoscopic extraction. Sevnow available for fragmentation, including the dissolution agents such as methyl tert-butyl or monooctanoin [8, 9]. Intracorporeal litho-
can be performed
manipulation
at the time
of endoscopy
by way of mechanical
or percu-
fragmentation
is 43/ rates better guided
to the biliary tract are routes. Large stones
diameter
of all bile
reported studies [1 -4], although study that used sonographically
in several previously than that in a recent
Other means of nonsurgical access via the transhepatic and transcholecystic of 2 cm in maximal
clearance
duct stones with the Siemens Lithostar Plus lithotripter 70 patients (61 %), which is not as high as the success
it is assumed
and,
of the
1 5 patients
that such small fragments
with
patients
are treated
fragments
smaller
on follow-up, pass
and
spontaneously.
This was confirmed in three of these 10 patients in whom follow-up ERC was performed. If the figures are analyzed so that those patients who remain asymptomatic are included with those patients whose ducts were cleared, then the combined figure for successful treatment would be 58/70 (83%),
which
is comparable
with that in other
series.
AJA:155,
ESWL
October1990
OF
BILE
When those patients who had successful fragmentation and dearance are compared with the unsuccessfully treated group of patients, it appears that, in our series, the most significant factor is the patient’s age. The more elderly the patient, the less successful is bile duct clearance. This may
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be because
these are high-risk,
generally
debilitated
stones
to be the
a high
means
of treating
difficult
biliary
success
drainage
and
active
pancreatitis
biliary
tree where
in several
those
other
different techniques
locations
real shock
2.
3. 4.
5.
6. 7.
8.
9.
within
have failed.
the
T, Stem M. Fragmentation of bile duct waves. Gastroenterology 1989;96:146-152
stones
by extracorpo-
Grener L, Wenzel H, Jakobeit C. Bihary lithotripsy of difficult bile duct stones. In: Burhenne HJ, Paumgartner G, Ferrucci JT (eds). Biliary lithotripsy II. Chicago: Year Book Medical, 1990:1 19-1 27 Moody FG, Amerson JA, Berci G, et al. Lithotnpsy for bile duct stones. Am J Surg 1989;158:241-247 Ginestal-Cruz A, Gnma N, Duarte ‘I, Tavora I, Correla J. Extracorporeal shock wave Iithotripsy for large common bile duct stones: an extension of the endoscopic approach. Lithotripsy Stone Dis 1989;4:272-281 Vaira D, D’Anna L Ainley C, et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989;2:431-433 Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AiR 1980;134:888-898 Burhenne NJ, Fache JS, Gibney AG, Rowley VA, Becker CD. Biliary lithotnpsy by extracorporeal shockwaves: integral part of nonsurgical intervention. AiR 1988;150:1279-1283 Haskin PH, Tepliclc SK, Sammon JK, Gambescia RA, zitorner N, Paulides CA. Monooctanoin infusion and stone removal through the transparenchymat tract: use in 17 patients. AiR 1987;148:185-188 Stokes KR, Falchuk KA, Clouse ME. Biliary duct stones: update on 54
cases after
percutaneous transhepatic removal. Radiology 1989;170:9991001 10. Park JH, Choi BI, Han MC, Sung KB. Choo 1W, Kim C-W. Percutaneous removal of residual intrahepatic stones. Radiology 1987;163:619-623 1 1 . Wholey MH, Smoot S. Choledocholithiasis: percutaneous pulverization with a high speed rotational catheter. AJR 1988;150:129-130 12. Bean WJ, Daughtry JD, Rodan BA, Mullin D. Utrasonic lithotripsy of retained common-bile-duct stones. AIR 1985;144:1275-1 276 13. Yoshimoto H, Ikeda 5, Tanaka M, Matsumoto 5, Kuroda Y. CholedochosIithotrtpsy and lithotomy for stones in the common ducts and gallbladder. Mn Surg 1989;210:576-582 Pious D, Weyman PJ, Marx MV. Ado of percutaneous intracorporeal electrohydrauliclithotripsy in the treatment of biliary tract calculi. Radiology 1989;170:989-993 Nishoka HS, Levins PC, Murray SC, Parrish JA, Anderson AR. Fragmentation of biliary calculi with tunable dye lasers. Gastroenterology 1987; 93:250-255 ElI C, Lux J, Hochberger J, MUller D, Dernling L. Laser Iithotnpsy of common bile duct stones. Gut 1988;29:746-751 Burhenne Ri, Stoller JL. Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Am J Burg 1985;149:632-653 Gibney AG, FacheJS, Becker CD. et aJ. COmbined surgical and radiological intervention for complicated cholelithiasis in high risk patients. Radiology copic electrohydraulic bile duct, intrahepatic
14.
15.
is not pres-
ant. Multiple treatment sessions may be necessary with the Siemens Lithostar; however, general or epidural anesthesia is not usually required, and selected patients can be treated on an outpatient basis. To date no deaths directly attributable to the effects of extracorporeal shock waves in the biliary tract have occurred, and complications are few. BESWL is a valuable adjuvant to standard interventional means of remov-
ing bile duct stones
1 . Sauerbruch
bile duct
rate of fragment clearance and low morbidity. The procedure is well tolerated, and there are no contraindications to treatment, providing the patient has adequate
with
safest
779
STONES
REFERENCES
patients,
so they are perhaps not treated as aggressively as younger patients. Our results differ somewhat from other series in that the maximal stone size and stone number have little bearing on the outcome of combined Iithotnpsy treatment with radiologic and/or endoscopic intervention. It was more difficult to clear fragments of IHD stones. Only two of five patients were discharged having had their ducts cleared. All patients had four or more stones, and three patients in whom the fragments were not extracted had underlying biliary disease, two with recurrent pyogenic cholangiohepatitis and one with Caroli disease. However, on follow-up, all three patients remain asymptomatic between 6 and 23 months after lithotnpsy treatment. Despite these small numbers of patients with IHD stones, we conclude that BESWL has a definite role in dearing stones from the intrahepatic biliary tree in patients with normal anatomy and has rendered three patients with an abnormal biliary tree asymptomatic. There are several alternatives to surgery for treating bile duct stones when standard percutaneous or endoscopic techniques have failed. The methods available depend on local expertise and access to appropriate equipment. We believe BESWL
DUCT
16. 17. 18.
1987;165:715-719 19. Ponchon T, Martin X, Barkun
A, Mestas
J-L,
Chavaillon
ExtracorporeaJ lithotnpsy of bile duct stones using stone localization. Gastroenterology 1990;98:726-732
A, Bousti#{232}reC.
ultrasonography
for
775
The Value of Extracorporeal Shock-Wave Lithotripsy in the Management of Bile Duct Stones
Stephen H. Le& J. Stephen Fache H. Joachim Burhenne
We evaluated the role of biliary extracorporeal shock-wave lithotripsy in treating 70 symptomatic patients with bile duct stones in whom endoscopic or percutaneous radiologic attempts at basket extraction had failed. Forty-four patients had common bile and/or
common
patients
hepatic
duct
had intrahepatic
elimination
of stone
stones,
fragments
stones were successfully
21 patients
duct stones. during
fragmented
had
cystic
duct
A total of 43 patients the initial
treatment
period.
yet not totally eliminated
stones,
(61%)
and
five
had complete
If patients
in whom
on initial hospital treat-
ment but who were asymptomatic at follow-up times of 8-22 months are included, the overall successful treatment rate was 83%. Stones were cleared in 26 of 44 common bile/hepatic duct stone patients, spontaneously in seven patients and after endoscopic or percutaneous radiologic intervention in 19 patients. Fifteen (71%) of 21 patients had cystic duct stones successfully cleared. The fragments in two of five patients with
intrahepatic
duct stones also were cleared.
Five patients
(7%) had minor side effects.
(10%) of 70 patients went on to have surgery. Complications after 30 days occurred in five patients (7%); two required repeated endoscopy with fragment extraction, two required placement of an endoprosthesis, and one died. We conclude that biliary extracorporeal shock-wave Iithotnpsy is valuable as an adjuvant to standard interventional techniques for removing bile duct stones. Seven
AJR 155:775-779,
October
1990
Biliary extracorporeal shock-wave method for treating bile duct stones
lithotripsy when other
(BESWL) is now a recognized methods have failed, and it has a
reported success rate of up to 93% [1-4]. The mainstay for treating bile duct stones is endoscopic retrograde cholangiography (ERG) and sphincterotomy with stone extraction, which in experienced hands has a successful stone clearance rate of around 90% [5]. If a T-tube is in place, then the radiologic means of stone extraction via the T-tube tract has a greater success rate (95%) for duct clearance with lower preliminary
morbidity experience
and mortality with BESWL
stones with a first-generation in the treatment
second-generation,
Received March 1 9, 1 990; accepted after revision May 7, 1990. I All authors: Department of Radiology, University of British Columbia and Vancouver Hospital, 855 W. 12th Ave., Vancouver, ada vsz i M9. Address reprint requests Burhenne.
0361-803X/90/1 554-0775 0 American Roentgen Ray Society
General BC, Canto H. J.
Subjects
lithotripter
of an additional
bathless
rates [6]. We have previously reported in treating both common duct and cystic
[7]. We now describe
62 patients
with
our duct
the value of BESWL
bile duct
stones
by using
a
lithotripter.
and Methods
Between October 1987 and October 1989, 70 symptomatic patients with bile duct stones were treated with BESWL after failure of radiologic or endoscopic attempts to remove some or all of these
stones
with
standard
basket
extraction
techniques.
All
radiologic
procedures
were performed in our institution, whereas ERC was performed by several different clinicians, and approximately one third of the ERC procedures were performed in outside institutions. Of the 70 patients, 46 had common bile duct (CBD) and/or common hepatic duct (CHD) stones, 21 patients had cystic duct (CD) stones, and five patients had intrahepatic duct (IHD)
LEE
776
stones. One patient had both CBD and CD stones treated, and one other patient had both CBD and IHD stones treated. The first eight patients were treated on a Dornier HM-3 lithotripter
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(Munich,
West
subsequent 62 Erlangen, West electrical nerve patients (16%), 62
patients
stones
Germany),
and
all required
epidural
anesthesia.
and
targeted
epidural
anesthesia
with
the
Lithostar
prone
position
in the
in one Plus, by
patient
(2%).
patients
58 using
overhead,
had
There
with IHD stones.
were
36
men
and
34
women,
years (mean, 71 .5 years). Previous formed in 41 (59%) of 70 patients. CD stones
had
an in situ
other
six
cholecystectomy. stones,
stones, ranged
Fifteen
gallbladder,
had had cholecystostomy The
with
range
of 21
high-risk
for acute
primary one
The
and Method
Opacification
Route
T-tube
Note.-CBD = common bile duct; cystic duct; IHD = intrahepatic duct. “ Includes one calcified stone that
disease.
0
1
10 0 8 1
2 1 2”
2 0
targeting. b All five
patients
had
retained
stones
did after
=
not
require
contrast
cholecystectomy.
three
with
disease,
and
recurrent one
with
was diagnosed
in
the
method
of targeting
catheters
(ES) were
are
catheters at the
placed
shown
in place all time
above
of failed the calculi
routinely.
In the treatment
of CBD/CHD
stones,
was
for
CD
(mean, 571 2). The average
1 3,655
1 .71 (range,
the
number
of shocks
(mean, 7254). The average was 2.26 (range, 1-7). stones
ranged
number
from
of treatment
given
number
of
1 231
to
sessions
1-4).
The number of shocks given to the five patients with IHD stones ranged from 551 3 to 9000 (mean, 7504). The average number of treatment sessions was one to four (mean, 2.4). No more than 4000 were interval
administered
in each
of 48 hr between
or contact
dissolution
treatment
sessions. agents
session, No oral
were
with
adjuvant
a minimum chemolith-
used.
Results
1
2 hepatic
none
was 2.5
IHD
5b
common
and
whenever possible. Percutaneous transhepatic catheters were inserted in 10 patients, eight of whom had prior ERG, with ES performed in five. Patients with cholangitis underwent lithotripsy after a period of biliary catheter drainage and appropriate antibiotic therapy. Patients who had no clinical evidence of infection were not given
time
of Targeting
Caroli
sphincterotomy
1). The
treatment sessions required The number of shocks given
CD
CHD
and
endoscopic (Fig.
disease:
with
who had nasobiliary
who
gallbladder
stones,
size treated
1990
cholecystectomy.
patients
25
Sonography
after
of opacification
extraction
solitary
stone
Mirizzi syndrome
ranged from 700 to 26,000
CBD and CHD
catheter
biliary one
Those patients
1.
undergone
stone
underlying
cholangitis.
patient
route
in Table
olysis
Nasobiliary catheter Transhepatic catheter Cholecystostomy catheter
had
scierosing
other
had
October
1 .1 7 cm).
with
retained
Route
16 (76%)
The maximum
cholangiohepatitis,
shocks 1: Opacification
patients,
patients
eight had two stones, six had three stones, four had four and 1 7 had five or more stones. Maximal stone diameter from 0.8 to 3.5 cm (mean, 2.13 cm).
TABLE
size,
antibiotics
of 29-99
CD
patients
pyogenic
had been per-
CD stump stones missed at CBD, CHD, and IHD patients, 16 had solitary
had
Of the
(71%)
all were
performed
patients
an age
cholecystectomy
21
cm (mean
had
biplanar
CD stones, one patient with a large CHD stone, and
impacted
one patient
the
Five
fluoroscopy with prior bile duct opacification. Fluoroscopy time ranged from 1 .1 to 1 1 .3 mm (mean, 5.3 mm). Stones in the other four patients were targeted sonographically with the patient supine by using the overhead module. These four patients included two patients with
Of
Of the
(94%)
AJR:155,
had more than two stones.
The
patients were treated on a Lithostar Plus (Siemens, Germany), with IV analgesia and/or transcutaneous stimulation in 51 patients (84%), no analgesia in 10
treated
ET AL.
duct; material
CD
=
for
Twenty-six (59%) of 44 patients with CBD/CHD stones were discharged from the hospital clear of fragments and stones. Of these 26 patients, seven passed fragments spontaneously as confirmed by follow-up cholangiography; five of the seven had had ES performed and the other two patients had T-tube tracts. The remaining 1 9 patients required adjuvant techniques to clear the bile ducts (Table 2). This included
Fig. 1.-A, Digital fluoroscopic image during targeting of 20-mm stone in common bile duct
with contrast
material
injected
via nasobiliary
catheter. Total of 3500 shocks were administered to largest stone and 1000 shocks to smaller stones in common hepatic duct. B, Nasobiliary cholangiogram 24 hr later reveals multiple stone fragments less than 5 mm in diameter.
A
B
ESWL
AJR:1 55, October1990
TABLE
2: Method
No. of Patients Cleared (%)
Site
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CBD/CHD CD IHD
a
=
=
endoscopic
Includes
Clearance
ERC
26/44 (59%) 15/21 (71%) 2/5 (40%)
Note.-CBD EAC
of Fragment
OF BILE
After
T-Tube Extraction
who required
STONES
777
Lithotripsy
Transhepatic Extraction
Transcholecystostomy Extraction
Spontaneous
12
5
2
0
7
1
1
0
9
4
1
0
1
0
0
common bile duct; CHD = common retrograde cholangiography.
one patient
DUCT
adjuvant
hepatic duct; CD
intracorporeal
1 2 patients with ES who underwent ERC on up to three separate occasions. One patient required balloon dilatation of a common hepatic duct stricture in order to completely clear the ducts of fragments (Fig. 2). Of the remaining 18 patients in whom the ducts could not be cleared with BESWL and adjuvant techniques, 1 5 had fragments smaller than 5 mm. The other three patients required surgery to clear the ducts, one because of a large 18mm stone refractory to treatment despite receiving 10,464 shocks during three treatment sessions, one because of recurrent pain from persisting fragments, and one because
cystic
=
electrohydraulic
duct;
IHD
=
intrahepatic
duct;
Iithotnpsy.
whether this patient has residual or recurrent stones in the biliary tree. When those patients in whom fragments were successfully
cleared at the initial time of treatment (26) are compared with those in whom the ducts did not clear (1 8), the difference
pancreatitis developed and the patient underwent cholecystectomy and bile duct clearance. The last two patients had
between the age groups is statistically significant. Patients who were treated successfully were younger (mean age, 66 years) than the patients in whom treatment failed (mean age, 75 years) (Wilcoxson Rank Sum Test, p = .0289). There was a tendency to use more shocks in the older group that was significant only at the 1 0% level (p = .835). No statistically significant difference was seen in stone size or stone number between the two groups (p = .1 707 and .1 41 6, respectively).
persistent Of the
Of the 21 patients with cystic duct stones, 1 5 (71 %) had stones and fragments cleared after a maximum of two litho-
fragments larger than 5 mm. 1 5 patients with retained fragments,
1 0 remain
asymptomatic with follow-up times of between 2 and 26 months (mean, 1 1 .9 months); all 10 had fragments smaller than 5 mm. Recurrent cholangitis developed in three patients and pancreatitis in one; all four had further ERC performed during which two patients had their ducts cleared and two had an endoprosthesis inserted because of failure to extract all residual stone fragments. The final patient had recurrent episodes of painless jaundice assumed to be due to his
underlying
primary
sclerosing
cholangitis.
Fig. 2.-A, T-tube cholangiogram shows two calculi in common hepatic duct(CHD)Iying proximal to a stricture right hepatic duct. B, cholangiogram
in CHD
and
obtained
one
calculus
24 hr after
in
litho-
tipsy shows successful fragmentation after 3021 shocks were targeted to all three stones.
It is not known
tripsy treatment sessions. with in situ gallbladders,
This eight
occluded
was
ment.
cystic
Eleven
duct
that
of the 1 5 patients
group included of whom had rendered
required
1 2 patients a previously
patent
further
after
treat-
percutaneous
extraction of stone fragments to clear the biliary tree. In four cases, fragments passed spontaneously most probably via the gallbladder
and cholecystostomy
tract
(Table
2). Of the
six patients in whom the cystic ducts were not adequately cleared, the three patients with in situ cholecystostomy cath-
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778
LEE
ET AL.
AJR:155,
October1990
eters went on to have cholecystectomy. The other three patients had retained cystic duct stump stones and are asymptomatic with a follow-up time of between 5 and 23 months. When the successfully treated CD stone group (n = 15) was compared with the unsuccessfully treated group (n = 6), the difference between the stone sizes, stone numbers, and number of shocks used was not statistically significant (Wil-
with conventional baskets [1 0], rotational catheters [1 1], ultrasonic contact lithotripsy [1 2], electrohydraulic lithotripsy [13, 14] and laser lithotripsy with a pulsed tunable dye [15], a continuous wave Nd-YAG laser, or a copper vapor laser
coxson Rank Sum Test, p = .929, .1 719, and .61 23, respectively). Of the five patients with IHD stones, two patients had their
that no strong evidence favoring any one of these techniques is available. In those cases in which suitable expertise is not
biliary tree cleared; both required adjuvant treatment, one via the transhepatic route and one via the endoscopic route (Table
2). Three
patients
the three were known hepatitis
and
remain
had partial
stone
to have recurrent asymptomatic
clearance;
pyogenic
at follow-up
two of
cholangiotimes
of 8
[16]. Some authors various methods tion, albeit
claim success rates of up to 100% for the of bile duct stone fragmentation and extrac-
in small selected
series
many of these cases of recurrent
are compatible with Caroli intrahepatic biliary radicle.
treatment
within
a large
dilated
Stones in six (9%) of 70 patients did not show evidence of fragmentation. This included two patients with CBD stones, one of whom required surgery and one of whom required insertion of an endoprosthesis. The other four cases were managed expectantly. In all 70 patients, recorded side effects were few; fever developed
in three
in one patient, were
treated
patients
patients,
and hemobilia conservatively
asymptomatic
hyperamylasemia
in one patient. without
All five patients
further
morbidity.
died after 30 days. One 90-year-old
weeks
after
lithotripsy
treatment.
This
woman
patient
We
initially
reported
our
stones occur.
with
BESWL
in the
and four cases of
cystic duct stones with the Dornier HM-3 lithotripter [7]. We have now treated another 62 patients with a Siemens Lithostar Plus lithotripter, which includes an overhead module for sonographic
targeting
and
produces
shock
of higher
waves
energy than the fluoroscopically targeted undercouch shock head. However, in only four patients were the stones adequately visualized with sonography to enable the use of the overhead module. The major route of cystic duct opacification
for targeting
was via a cholecystostomy
a mini-cholecystostomy
died 7
risk patients
who present
1 8]. Through
this tract,
cholangitis and septicemia in which satisfactory biliary drainage was not achieved despite successful fragmentation and repeated attempts to clear the ducts at ERC in an outside institution. The other two deaths were in patients aged 85 and 95 who were discovered on follow-up ERG to have malignant bile duct strictures that were satisfactorily stented, but both died approximately 2 months after stent insertion.
or retained
experience
of four cases of bile duct stones
Three
had recurrent
data suggest
available or stones are not removed, BESWL has proved to be extremely valuable in fragmenting intrahepatic, bile duct, and cystic duct stones such that fragments either pass spontaneously or can easily be removed by adjuvant techniques. Few cases should require surgery with its attendant risks, especially in the elderly and high-risk age groups in which
and 22 months. The third patient also remains asymptomatic despite retained stone fragments, the appearances of which disease,
[1 4]. Current
under
for both bile drainage By treating have been
patients
tract, as we perform
local anesthetic
access
is gained
manner,
high-
disease
[17,
to the gallbladder
and early radiologic in this
stone
extraction.
morbidity
significantly reduced without BESWL has a significant
cystectomy.
in those
with acute gallbladder
and mortality the need for chole-
role to play in the
management of impacted cystic duct stones when percutaneous extraction has failed. Treatment can be performed either during the same hospital admission, within 5-1 0 days
of cholecystostomy, or on an outpatient basis. In either situation, symptoms and signs of acute gallbladder inflammation should have resolved before treatment with BESWL. Discussion
Our overall
There are several nonsurgical means of treating bile duct stones, of which ES with stone extraction is the most widely used. If a postoperative T-tube is in place, then percutaneous radiologic
stone
should
extraction
be the method
morbidity
with
of choice
and zero mortality
the
Burhenne
because
technique
of its much lower
rate [6].
success
rate for fragment
lithotripsy
[1 9]. There are several possible explanations.
First,
in our patients we do not pursue fragments smaller than 5 mm that remain within the bile ducts of patients who have
had adequate
sphincterotomies.
These
expectantly
in excess
are notoriously
than 5 mm in size, 1 0 remain asymptomatic
to remove by mented before eral means are use of contact ether (MTBE) tripsy
taneous
difficult
any nonsurgical route and have to be fragpercutaneous or endoscopic extraction. Sevnow available for fragmentation, including the dissolution agents such as methyl tert-butyl or monooctanoin [8, 9]. Intracorporeal litho-
can be performed
manipulation
at the time
of endoscopy
by way of mechanical
or percu-
fragmentation
is 43/ rates better guided
to the biliary tract are routes. Large stones
diameter
of all bile
reported studies [1 -4], although study that used sonographically
in several previously than that in a recent
Other means of nonsurgical access via the transhepatic and transcholecystic of 2 cm in maximal
clearance
duct stones with the Siemens Lithostar Plus lithotripter 70 patients (61 %), which is not as high as the success
it is assumed
and,
of the
1 5 patients
that such small fragments
with
patients
are treated
fragments
smaller
on follow-up, pass
and
spontaneously.
This was confirmed in three of these 10 patients in whom follow-up ERC was performed. If the figures are analyzed so that those patients who remain asymptomatic are included with those patients whose ducts were cleared, then the combined figure for successful treatment would be 58/70 (83%),
which
is comparable
with that in other
series.
AJA:155,
ESWL
October1990
OF
BILE
When those patients who had successful fragmentation and dearance are compared with the unsuccessfully treated group of patients, it appears that, in our series, the most significant factor is the patient’s age. The more elderly the patient, the less successful is bile duct clearance. This may
Downloaded from www.ajronline.org by 89.66.25.44 on 10/24/15 from IP address 89.66.25.44. Copyright ARRS. For personal use only; all rights reserved
be because
these are high-risk,
generally
debilitated
stones
to be the
a high
means
of treating
difficult
biliary
success
drainage
and
active
pancreatitis
biliary
tree where
in several
those
other
different techniques
locations
real shock
2.
3. 4.
5.
6. 7.
8.
9.
within
have failed.
the
T, Stem M. Fragmentation of bile duct waves. Gastroenterology 1989;96:146-152
stones
by extracorpo-
Grener L, Wenzel H, Jakobeit C. Bihary lithotripsy of difficult bile duct stones. In: Burhenne HJ, Paumgartner G, Ferrucci JT (eds). Biliary lithotripsy II. Chicago: Year Book Medical, 1990:1 19-1 27 Moody FG, Amerson JA, Berci G, et al. Lithotnpsy for bile duct stones. Am J Surg 1989;158:241-247 Ginestal-Cruz A, Gnma N, Duarte ‘I, Tavora I, Correla J. Extracorporeal shock wave Iithotripsy for large common bile duct stones: an extension of the endoscopic approach. Lithotripsy Stone Dis 1989;4:272-281 Vaira D, D’Anna L Ainley C, et al. Endoscopic sphincterotomy in 1000 consecutive patients. Lancet 1989;2:431-433 Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AiR 1980;134:888-898 Burhenne NJ, Fache JS, Gibney AG, Rowley VA, Becker CD. Biliary lithotnpsy by extracorporeal shockwaves: integral part of nonsurgical intervention. AiR 1988;150:1279-1283 Haskin PH, Tepliclc SK, Sammon JK, Gambescia RA, zitorner N, Paulides CA. Monooctanoin infusion and stone removal through the transparenchymat tract: use in 17 patients. AiR 1987;148:185-188 Stokes KR, Falchuk KA, Clouse ME. Biliary duct stones: update on 54
cases after
percutaneous transhepatic removal. Radiology 1989;170:9991001 10. Park JH, Choi BI, Han MC, Sung KB. Choo 1W, Kim C-W. Percutaneous removal of residual intrahepatic stones. Radiology 1987;163:619-623 1 1 . Wholey MH, Smoot S. Choledocholithiasis: percutaneous pulverization with a high speed rotational catheter. AJR 1988;150:129-130 12. Bean WJ, Daughtry JD, Rodan BA, Mullin D. Utrasonic lithotripsy of retained common-bile-duct stones. AIR 1985;144:1275-1 276 13. Yoshimoto H, Ikeda 5, Tanaka M, Matsumoto 5, Kuroda Y. CholedochosIithotrtpsy and lithotomy for stones in the common ducts and gallbladder. Mn Surg 1989;210:576-582 Pious D, Weyman PJ, Marx MV. Ado of percutaneous intracorporeal electrohydrauliclithotripsy in the treatment of biliary tract calculi. Radiology 1989;170:989-993 Nishoka HS, Levins PC, Murray SC, Parrish JA, Anderson AR. Fragmentation of biliary calculi with tunable dye lasers. Gastroenterology 1987; 93:250-255 ElI C, Lux J, Hochberger J, MUller D, Dernling L. Laser Iithotnpsy of common bile duct stones. Gut 1988;29:746-751 Burhenne Ri, Stoller JL. Minicholecystostomy and radiologic stone extraction in high-risk cholelithiasis patients. Am J Burg 1985;149:632-653 Gibney AG, FacheJS, Becker CD. et aJ. COmbined surgical and radiological intervention for complicated cholelithiasis in high risk patients. Radiology copic electrohydraulic bile duct, intrahepatic
14.
15.
is not pres-
ant. Multiple treatment sessions may be necessary with the Siemens Lithostar; however, general or epidural anesthesia is not usually required, and selected patients can be treated on an outpatient basis. To date no deaths directly attributable to the effects of extracorporeal shock waves in the biliary tract have occurred, and complications are few. BESWL is a valuable adjuvant to standard interventional means of remov-
ing bile duct stones
1 . Sauerbruch
bile duct
rate of fragment clearance and low morbidity. The procedure is well tolerated, and there are no contraindications to treatment, providing the patient has adequate
with
safest
779
STONES
REFERENCES
patients,
so they are perhaps not treated as aggressively as younger patients. Our results differ somewhat from other series in that the maximal stone size and stone number have little bearing on the outcome of combined Iithotnpsy treatment with radiologic and/or endoscopic intervention. It was more difficult to clear fragments of IHD stones. Only two of five patients were discharged having had their ducts cleared. All patients had four or more stones, and three patients in whom the fragments were not extracted had underlying biliary disease, two with recurrent pyogenic cholangiohepatitis and one with Caroli disease. However, on follow-up, all three patients remain asymptomatic between 6 and 23 months after lithotnpsy treatment. Despite these small numbers of patients with IHD stones, we conclude that BESWL has a definite role in dearing stones from the intrahepatic biliary tree in patients with normal anatomy and has rendered three patients with an abnormal biliary tree asymptomatic. There are several alternatives to surgery for treating bile duct stones when standard percutaneous or endoscopic techniques have failed. The methods available depend on local expertise and access to appropriate equipment. We believe BESWL
DUCT
16. 17. 18.
1987;165:715-719 19. Ponchon T, Martin X, Barkun
A, Mestas
J-L,
Chavaillon
ExtracorporeaJ lithotnpsy of bile duct stones using stone localization. Gastroenterology 1990;98:726-732
A, Bousti#{232}reC.
ultrasonography
for
