Lithotomy for Stones in the Common Bile Duct,

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  • Choledochoscopic Electrohydraulic Lithotripsy andLithotomy for Stones in the Common Bile Duct,Intrahepatic Ducts, and Gallbladder


    Choledochoscopic lithotomy with the aid of electrohydrauliclithotripsy was performed in 40 patients, including 16 patientswith choledocholithiasis, 15 with hepatolithiasis, and 9 withcholecystolithiasis. As a route for the choledochoscopy, a T-tubetract, external cholecystostomy, or jejunal limb of hepaticoje-junostomy was used in nine patients, while percutaneous trans-hepatic biliary drainage followed by dilatation of the track wasestablished in 31 patients. The largest cholesterol stone measured55 mm by 33 mm and the largest bilirubinate stone measured52 mm by 37 mm. The stones were disintegrated in all but onepatient in whom choledochoscopic access to a gallstone was dif-ficult due to deformity of the gallbladder. Complete removal ofthe stones was achieved in 38 of 39 patients. In a patient withhepatolithiasis, small stones located deep in inaccessiblebranches of the intrahepatic duct remained unremovable. Therewere no serious complications. Minor complications occurred,including bleeding from the bile duct mucosa in four patientsand postprocedure chills and fever in three. Choledochoscopiclithotomy with electrohydraulic lithotripsy is efficient and usefulto remove biliary calculi in patients who are poor surgical risks.

    A VARIETY OF NONSURGICAL approaches for thetreatment of cholelithiasis are available. Endo-scopic sphincterotomy (EST)"2 and choledo-

    choscopic lithotomy3l4 have gained wide acceptance.However huge stones and impacted stones continue topresent a technical problem. Chemical dissolution5'6 andfragmentation of gallstones using extracorporeal shockwave7 are receiving enthusiastic trials but are not alwayssuccessful.

    Previously we reported the use of electrohydrauliclithotripsy (EHL) under direct visual control during cho-ledochoscopy to remove intrahepatic stones.8 This report

    Correspondences and reprint requests: Hideo Yoshimoto, M.D., De-partment of Surgery I, Fukuoka University School of Medicine, 7-45-1,Nanakuma, Fukuoka 814-01, Japan.

    This study was supported in part by the clinical research fund fromthe Fukuoka University Hospital and the Japanese Foundation for Re-search and Promotion of Endoscopy.

    Accepted for publication: January 19, 1989.

    From the Departments of Surgery I, Fukuoka UniversitySchool of Medicine, and Kyushu University Faculty of

    Medicine, Fukuoka, Japan

    addresses the results of application of the EHL techniquein a new series of 40 patients. The present series includespatients with calculi in the common bile duct, gallbladder,and the intrahepatic ducts.

    Materials and Methods


    From June 1985 to June 1988, choledochoscopic elec-trohydraulic lithotripsy and lithotomy were performed in40 patients with stones in the common bile duct, intra-hepatic ducts, or gallbladder (Table 1). The series included16 men and 24 women, ranging in age from 45 to 87years. Eleven patients were between 70 and 80 years ofage and seven patients were older than 80 years. All thesepatients had one or more reasons that rendered nonsur-gical removal of the stones preferable (Table 1).The size of the stone (stones) measured on direct chol-

    angiograms was greater than 30 mm in diameter in 9patients, between 20 mm and 30 mm in 10 patients, andbetween 7 mm to 20 mm in the remaining 21 patients.The stone was impacted at the distal common bile ductin 12 patients. Twenty-three patients had less than 4stones, 6 patients had 5 to 10 stones, and 11 patients hadnumerous stones. Eleven patients had cholesterol stones,the largest of which measured 55 mm by 30 mm, whilethe other 29 patients had pigment stones, the largest ofwhich measured 52 mm by 37 mm. Computed tomog-raphy performed in one half of these patients revealeddistinct calcification of the stones in seven patients.Common bile duct stones. Eight of 16 patients with

    common bile duct stones were high surgical risks; 4 pa-tients were older than 80 years, 3 had a history ofmultiple



    Electrohydraulic Lithotripsy


    Indications Remarks Patients

    Choledocholithiasis Residual stones with a 5biliary tube in place

    Extraction failed after EST* 5Difficult duodenoscopic 6


    Hepatolithiasis Polysurgery 4Biliary cirrhosis 4Retained stones 3Advanced age (over 77 years) 2Previous operation for I

    gallbladder cancerDetected by chance without Isymptoms

    Cholecystolithiasis Advanced age 4Polysurgery 2Chronic renal failure ICongestive heart failure ISchizophrenia I

    Total 40

    * EST, endoscopic sphincterotomy.

    abdominal operations, 1 had spinal cord injury, and 1had ischemic heart disease. Twelve of these patients hadundergone cholecystectomy previously, while 4 patientshad gallbladders with (1 patient) or without (3 patients)gallstones.

    Five of the 16 patients had a T-tube (4 patients) or apercutaneous transhepatic biliary drainage (PTBD) tube(1 patient) in place. Five patients had had EST performedbut duodenoscopic extraction had failed because thestones were huge (larger than 30 mm) in 3 patients, im-pacted and immobile in 1, or located beyond a bile ductstenosis due to chronic pancreatitis in 1 patient. The duo-denoscopic approach was considered inadequate for var-ious reasons in the other six patients. Two of these hadthe anomalous union of the pancreatic and bile ducts.One had undergone Billroth II gastrectomy. The stonewas impacted at the distal common bile duct in one. Thepapilla was situated within a diverticulum in one. A hugestone (55 by 30 mm) occupied the entire lumen of thebile duct in another patient.

    Intrahepatic stones. Fifteen patients had stones in theintrahepatic ducts. All but one patients with intrahepaticstones had a history of one or more biliary operations.Fourteen of the 15 patients had a reason for the nonop-erative approach for removal of the intrahepatic stones(Table 1). An asymptomatic patient in whom the intra-hepatic stones were detected by echography refused sur-gical treatment.

    Fourteen of these 15 patients were considered to haveprimary hepatolithiasis, which was associated with com-

    mon bile duct stones in four patients. Another patienthad hepatolithiasis secondary to stenosis of the commonhepatic duct injured at cholecystectomy 15 years before.In two patients, the intrahepatic stones were first discov-ered by T-tube cholangiography. Four patients had un-dergone EST for removal of common bile duct stonesand one patient had transduodenal sphincteroplasty, butthe intrahepatic stones were retained.

    Gallbladder stones. Nine patients had stones in thegallbladder. Two of them presented with jaundice andcholangitis due to a so-called confluence stone and hadPTBD performed (Fig. 1). Two other patients had an ex-ternal cholecystostomy for acute cholecystitis; one ofthemhad undergone transhepatic drainage of a liver abscesssecondary to cholecystitis. The remaining five patientshad percutaneous transhepatic gallbladder drainage(PTGBD) to provide a route for lithotomy. All of thesenine patients were poor operative risks (Table 1).


    An electric surge current generator (Lithotron EL-2 1,Walz Elektronik Gmbh, Rohrdorf, West Germany) witha 4.5 French size lithotripsy probe was used. The intensityof discharge was usually set at 2 with a frequency of 20per second. When the stone was hard, the intensity wasincreased to 3.A small-caliber choledochofiberscope (4.8 mm, model

    CHF Pl 0, Olympus Optical Co., Tokyo, Japan) was usu-ally used. In cases in which the stones were larger than25 mm in diameter, a choledochoscope with a larger di-ameter (6.5 mm, model CHF B3, Olympus Optical Co.,Tokyo, Japan) was used, because more rapid infusion ofsaline through its larger biopsy channel permitted us tokeep the endoscopic view clear during the procedure.

    Routesfor Choledochoscopy

    Table 2 shows the routes for insertion of the choledo-choscope and lithotripsy instruments. A PTBD tract wasused after dilatation in 26 patients, a T-tube tract in 6, aPTGBD tract in 5, and an external cholecystostomy tractin 2 patients. In another patient, a blind end ofthe jejunallimb subcutaneously implanted at previous Roux-en-Yhepaticojejunostomy was reopened and used as a routefor choledochoscopy.


    To establish the percutaneous transhepatic route, theintrahepatic duct or gallbladder was entered under ultra-sonic guidance. Using a guide wire technique, a 7.2 Frenchbiliary drainage catheter for PTBD or a 10 French Malecotcatheter for PTGBD (Cook, Inc., Markham, Ontario,Canada) was placed in the common bile duct or gallblad-der, respectively. The catheter tract was dilated twice a

    Vol. 210 * No. S

  • YOSHIMOTO AND OTHERS Ann. Surg. * November 1989

    FIGS. lA-C. Cholangiograms in a 84-year-old woman with a huge con-fluence stone. The patient also had diabetes mellitus and cirrhosis of theliver. (A) Percutaneous transhepatic biliarv drainage under ultrasoundguidance was performed to relieve cholangitis. A stone, about 40 mmin diameter, occluding the confluence of the cvstic duct and commonbile duct. was visualized. (B) After dilatation of the sinus tract. a cho-ledochoscope was introduced into the bile duct and an electrohydrauliclithotripsy probe was advanced through the catheter channel. The probewas approximated closely to the stone under direct visual control. (C)The stone was broken into several fragments after application of dischargesparks.

    week by replacing the catheter with a larger one by 2French size. A 16 to 20 French (5.3 to 6.7