Treatment of bile duct stones: value of laser lithotripsy delivered via percutaneous endoscopy.

Extraction of stones from the bile ducts via standard endoscopic techniques, a percutaneous transhepatic approach, or a T-tube track can be unsuccessful. We report our preliminary experience with a combination of percutaneous cholangioscopy and dye laser lithotripsy. Flash lamp-excited dye laser (504 nm) lithotripsy delivered by percutaneous cholangioscopy (12 F) was evaluated in 13 patients with stones in the bile ducts. Conventional endoscopic treatment had not been attempted in 4 patients after hepaticojejunostomy and had failed in 3 patients after gastric bypass surgery or gastrectomy, and in 6 patients because of technical difficulties, i.e. due mainly to largeness of stones. In 12 patients a percutaneous transhepatic route was used. In 1 patient the T-tube track was used as access to the bile ducts. Laser lithotripsy resulted in successful fragmentation of stones in 12 patients (92%). The bile ducts cleared spontaneously in 2 patients only. Using additional techniques, i.e. sphincterotomy and stent insertion, the overall combined success rate for duct clearance after laser fragmentation was 100%. Four patients had a retrograde endoscopic sphincterotomy after failed attempts for stone removal at endoscopic retrograde cholangioscopy. Two patients had an antegrade fluoroscopically monitored sphincterotomy. Bleeding complications occurred in 2 patients. This accounted for a high rate (15%) of severe complications. The intrahepatic bleeding in 1 patient was due to an intrahepatic vessel injury by the 13-F sheath. The periampullary bleeding in the other patient occurred after an antegrade papillotomy. Pulsed dye laser lithotripsy proved to be an effective technique in patients with difficult bile duct stones. The main problem of a per cutaneous approach is the complete removal of the fragmented stones, which requires additional procedures in most cases. The percutaneous access is time-consuming and bears a relatively high risk of major bleeding complications. It should therefore be restricted to cases in which conventional endoscopic procedures are impossible or unsuccessful.