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Extracorporeal shock-wave lithotripsy for the management of bile duct stones: Is it always a safe procedure?
GASTROENTEROLOGY
1991:101:1754-1761
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence Section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Extracorporeal Shock-Wave Lithotripsy for the Management of Bile Duct Stones: Is It Always a Safe Procedure? Dear Sir: For a small group of patients with very large bile duct stones in whom endoscopic removal of the calculi is not possible and surgery is to be avoided, extracorporeal found to be efficacious
shock-wave
with a low incidence
We have treated more than 200 patients
lithotripsy
has been
of serious side effects.
with cholecystolithiasis
with extracorporeal shock-wave lithotripsy (ESWL) using a Richard Wolfe-Piezolith 2200 without analgesia or anesthetic with a minimum complication common
rate. We have also treated
bile duct stones
complication
20 patients
with
a life-threatening
of this latter procedure.
An 81-year-old cholangitis.
and wish to report
woman was admitted with a history of recurrent
An ultrasound
choledocholithiasis,
examination
and an obstructed
confirmed biliary
cholelithiasis,
system.
An endo-
scopic retrograde cholangiopancreatographic examination confirmed the presence of multiple large calculi in a very dilated common bile duct, and a wide sphincterotomy was performed. However, these calculi were too large to be extracted endoscopitally.
A nasobiliary
tube was left in situ,
and the patient
was
referred for ESWL. The two principal stones were easily localized and targeted through ultrasonography, and the patient received initially a total of 5500 shock waves at maximum power 4 spread over two treatments. There was some evidence of stone fragmentation, and the patient further treatments. Unfortunately,
received
during
a further
her subsequent
5000 shocks
during two
cholangiogram
2 hours
after her last treatment, the patient developed severe refractory shock with symptoms of blood loss and copious bleeding up the nasobiliary tube, necessitating transfusion of 2 U of blood and an emergency laparotomy. The final cholangiogram showed contrast traversing the intrahepatic bile duct and entering a small portal vein radicle. The nasobiliary tube was removed immediately and showed no signs of damage that might have suggested any adverse effect of the shock waves on the tube itself. At the time of surgery, there was no evidence of extravasation of bile outside the bile duct, but within the very dilated common bile duct there was a large volume of blood under pressure
and many
very sharp gallstone fragments. Some of these fragments were impacted within the bile duct wall. Choledochoscopy revealed evidence of ulceration, inflammation, and active bleeding from within the proximal bile ducts. The stone fragments were removed, duct lavage was undertaken, and the bleeding spontaneously diminished. Following the exploration of the common bile duct and cholecystectomy, this patient had a relatively unremarkable convalescence. At no time was there any evidence of a coagulopathy or any indication that sepsis played a significant role in this patient’s subsequent problems. It is postulated that the final shattering of the large stone caused a sharp fragment to traverse the bile duct wall and damage a portal vein radicle, which was then opacified by contrast injected down the nasobiliary tube. The amount of blood in the common bile duct
and the pressure it was under served to indicate what a lifethreatening complication this was. Sauerbruch (1) reported the results of a prospective multicenter trial of ESWL for patients with common bile duct stones. This study reports the largest series of patients treated today, including 113 patients selected from more than 1000 patients referred to the 11 cooperating centers for endoscopic treatment of choledocholithiasis. There was a significant number of complications occurring in 36%, and although these were generally minor, more severe complications were also noted such as gallbladder empyema, perforation of a duodenal diverticulum, and at least one death. However, the particular complication that we report has not previously been noted. The role of ESWL in cholelithiasis may be limited, and it would appear that the role of lithotripsy in choledocholithiasis is even smaller and yet to be adequately defined. Its future use will be governed largely by the careful assessment of its safety and efficacy. W.E. G. THOMAS, M.S.,F.R.C.S. I’. M. CHRISTIE, M.B. Ch.B.,F.R.A.C.S. B. ROSS, M.B.,Ch.B.,F.R.C.R., M.D.
Departments of Surgery and Radiology Royal Hallamshire Hospital Glossop Road Sheffield SlO ZJF, England 1. Sauerbruch T, Stern M. Fragmentation of bile duct stones by extracorporeal shock waves. A new approach to biliary calculi after failure of routine endoscopic measures. Gastroenterology 1989;96:146-152. Reply. Since the first report on ESWL of gallbladder and bile duct stones (l), a considerable number of patients has been treated worldwide. Extracorporeal shock wave lithotripsy of bile duct stones is confined to those patients with calculi primarily not amenable to endoscopic extraction. According to the fully published series with more than 15 patients (2), fragmentation of the stones is achieved in 80%-90% of the patients. However, stone disintegration is often rather coarse requiring endoscopic extraction of fragments in about 70% of the patients. This leads to a biliary tree clearance rate of about 80% of patients with bile duct stones primarily not amenable to endoscopic removal. It has been shown that lithotripsy of bile duct calculi can be achieved with different types of lithotripters using electrohydraulit, electromagnetic, or piezoceramic shock-wave generation. Major adverse effects have been reported in between 0% and ,- 10% of patients (2). According to our own experience, the most important complication is septic temperatures following the procedure. This has led to the recommendation of antibiotic prophylaxis for ESWL of bile duct stones. We recently reviewed our own patients with more than 100 cases over a follow-up time of nearly 2 years. One patient died in the hospital of causes not directly related to shock-wave treatment (3). In numerous further smaller studies, no deaths were reported. Transient hemobilia is a rare event (according to our experience, 3% of all treated patients), and signs of tissue damage with liver hematoma are observed in no more than 1% of patients. In the present letter, Thomas et al. describe a patient with severe hemobilia following four shock-wave sessions with a piezo-
1991:101:1754-1761
CORRESPONDENCE Readers are encouraged to write Letters to the Editor concerning articles that have been published in GASTROENTEROLOGY. Short, general comments are also considered, but use of the Correspondence Section for publication of original data in preliminary form is not encouraged. Letters should be typewritten double-spaced and submitted in triplicate.
Extracorporeal Shock-Wave Lithotripsy for the Management of Bile Duct Stones: Is It Always a Safe Procedure? Dear Sir: For a small group of patients with very large bile duct stones in whom endoscopic removal of the calculi is not possible and surgery is to be avoided, extracorporeal found to be efficacious
shock-wave
with a low incidence
We have treated more than 200 patients
lithotripsy
has been
of serious side effects.
with cholecystolithiasis
with extracorporeal shock-wave lithotripsy (ESWL) using a Richard Wolfe-Piezolith 2200 without analgesia or anesthetic with a minimum complication common
rate. We have also treated
bile duct stones
complication
20 patients
with
a life-threatening
of this latter procedure.
An 81-year-old cholangitis.
and wish to report
woman was admitted with a history of recurrent
An ultrasound
choledocholithiasis,
examination
and an obstructed
confirmed biliary
cholelithiasis,
system.
An endo-
scopic retrograde cholangiopancreatographic examination confirmed the presence of multiple large calculi in a very dilated common bile duct, and a wide sphincterotomy was performed. However, these calculi were too large to be extracted endoscopitally.
A nasobiliary
tube was left in situ,
and the patient
was
referred for ESWL. The two principal stones were easily localized and targeted through ultrasonography, and the patient received initially a total of 5500 shock waves at maximum power 4 spread over two treatments. There was some evidence of stone fragmentation, and the patient further treatments. Unfortunately,
received
during
a further
her subsequent
5000 shocks
during two
cholangiogram
2 hours
after her last treatment, the patient developed severe refractory shock with symptoms of blood loss and copious bleeding up the nasobiliary tube, necessitating transfusion of 2 U of blood and an emergency laparotomy. The final cholangiogram showed contrast traversing the intrahepatic bile duct and entering a small portal vein radicle. The nasobiliary tube was removed immediately and showed no signs of damage that might have suggested any adverse effect of the shock waves on the tube itself. At the time of surgery, there was no evidence of extravasation of bile outside the bile duct, but within the very dilated common bile duct there was a large volume of blood under pressure
and many
very sharp gallstone fragments. Some of these fragments were impacted within the bile duct wall. Choledochoscopy revealed evidence of ulceration, inflammation, and active bleeding from within the proximal bile ducts. The stone fragments were removed, duct lavage was undertaken, and the bleeding spontaneously diminished. Following the exploration of the common bile duct and cholecystectomy, this patient had a relatively unremarkable convalescence. At no time was there any evidence of a coagulopathy or any indication that sepsis played a significant role in this patient’s subsequent problems. It is postulated that the final shattering of the large stone caused a sharp fragment to traverse the bile duct wall and damage a portal vein radicle, which was then opacified by contrast injected down the nasobiliary tube. The amount of blood in the common bile duct
and the pressure it was under served to indicate what a lifethreatening complication this was. Sauerbruch (1) reported the results of a prospective multicenter trial of ESWL for patients with common bile duct stones. This study reports the largest series of patients treated today, including 113 patients selected from more than 1000 patients referred to the 11 cooperating centers for endoscopic treatment of choledocholithiasis. There was a significant number of complications occurring in 36%, and although these were generally minor, more severe complications were also noted such as gallbladder empyema, perforation of a duodenal diverticulum, and at least one death. However, the particular complication that we report has not previously been noted. The role of ESWL in cholelithiasis may be limited, and it would appear that the role of lithotripsy in choledocholithiasis is even smaller and yet to be adequately defined. Its future use will be governed largely by the careful assessment of its safety and efficacy. W.E. G. THOMAS, M.S.,F.R.C.S. I’. M. CHRISTIE, M.B. Ch.B.,F.R.A.C.S. B. ROSS, M.B.,Ch.B.,F.R.C.R., M.D.
Departments of Surgery and Radiology Royal Hallamshire Hospital Glossop Road Sheffield SlO ZJF, England 1. Sauerbruch T, Stern M. Fragmentation of bile duct stones by extracorporeal shock waves. A new approach to biliary calculi after failure of routine endoscopic measures. Gastroenterology 1989;96:146-152. Reply. Since the first report on ESWL of gallbladder and bile duct stones (l), a considerable number of patients has been treated worldwide. Extracorporeal shock wave lithotripsy of bile duct stones is confined to those patients with calculi primarily not amenable to endoscopic extraction. According to the fully published series with more than 15 patients (2), fragmentation of the stones is achieved in 80%-90% of the patients. However, stone disintegration is often rather coarse requiring endoscopic extraction of fragments in about 70% of the patients. This leads to a biliary tree clearance rate of about 80% of patients with bile duct stones primarily not amenable to endoscopic removal. It has been shown that lithotripsy of bile duct calculi can be achieved with different types of lithotripters using electrohydraulit, electromagnetic, or piezoceramic shock-wave generation. Major adverse effects have been reported in between 0% and ,- 10% of patients (2). According to our own experience, the most important complication is septic temperatures following the procedure. This has led to the recommendation of antibiotic prophylaxis for ESWL of bile duct stones. We recently reviewed our own patients with more than 100 cases over a follow-up time of nearly 2 years. One patient died in the hospital of causes not directly related to shock-wave treatment (3). In numerous further smaller studies, no deaths were reported. Transient hemobilia is a rare event (according to our experience, 3% of all treated patients), and signs of tissue damage with liver hematoma are observed in no more than 1% of patients. In the present letter, Thomas et al. describe a patient with severe hemobilia following four shock-wave sessions with a piezo-