Background and study aim: Choledocholithiasis is a common disease in the West. Lithotripsy by mechanical methods using baskets and by laser or electrohydraulic methods varies in effectiveness. With argon plasma coagulation (APC), high temperatures are used for devitalization and fragmentation; cryogenic techniques use the selective controlled application of freeze-thaw cycles to devitalize pathological tissue; and the dissecting water jet exploits the high pressure action of a thin laminar jet. We aimed to assess the feasibility and effectiveness of APC, cryotechnology, and the dissecting water jet as options for the fragmentation of bile duct stones.
Methods: In an in vitro feasibility study, we evaluated the fragmentation of 120 bile duct stones treated with the three methods. Primary measures were assessment of the fragmentation rate, fragmentation effect, and energy application for each technology.
Results: Fragmentation was seen in only 10 % of stones treated cryogenically using liquid nitrogen. APC at a power setting of 30 – 50 W fragmented all the cholesterol stones, but results with hard pigment stones were unsatisfactory even at high energies of a 100 W setting and long application time. Using the water jet, all 40 stones (100 %) were cracked effectively and completely with a pressure of 10 – 50 bar.
Conclusion: In this feasibility study, the first of its kind, only the water-jet device demonstrated efficient fragmentation of large bile duct stones in vitro. APC and cryotechnology are not suitable for the treatment of bile duct stones; the fragmentation rate with these methods was inadequate.
References
-
1
Binmoeller K F, Schafer T W.
Endoscopic management of bile duct stones.
J Clin Gastroenterol.
2001;
32
106-118
-
2
Kim H J, Choi H S, Park J H. et al .
Factors influencing the technical difficulty of endoscopic clearance of bile duct stones.
Gastrointest Endosc.
2007;
66
1154-1160
-
3
Garg P K, Tandon R K, Ahuja V. et al .
Predictors of unsuccessful mechanical lithotripsy and endoscopic clearance of large bile duct stones.
Gastrointest Endosc.
2004;
59
601-605
-
4
Hochberger J, Tex S, Maiss J. et al .
Management of difficult common bile duct stones.
Gastrointest Endosc Clin N Am.
2003;
13
623-634
-
5
Lee S H, Park J K, Yoon W J. et al .
How to predict the outcome of endoscopic mechanical lithotripsy in patients with difficult bile duct stones?.
Scand J Gastroenterol.
2007;
42
1006-1010
-
6
McHenry L, Lehman G.
Difficult bile duct stones.
Curr Treat Options Gastroenterol.
2006;
9
123-132
-
7
Neuhaus H.
Endoscopic and percutaneous treatment of difficult bile duct stones.
Endoscopy.
2003;
35
31-34
-
8
Arya N, Nelles S E, Haber G B. et al .
Electrohydraulic lithotripsy in 111 patients: a safe and effective therapy for difficult bile duct stones.
Am J Gastroenterol.
2004;
99
2330-2334
-
9
Hochberger J, Gruber E, Wirtz P. et al .
Lithotripsy of gallstones by means of a quality-switched giant-pulse neodymium:yttrium-aluminum-garnet laser. Basic in vitro studies using a highly flexible fiber system.
Gastroenterology.
1991;
101
1391-1398
-
10
Jakobs R, Maier M, Kohler B. et al .
Peroral laser lithotripsy of difficult intrahepatic and extrahepatic bile duct stones: laser effectiveness using an automatic stone-tissue discrimination system.
Am J Gastroenterol.
1996;
91
468-473
-
11
Jakobs R, Riemann J F.
Laser fragmentation of pancreatic duct stones using a rhodamine laser with an automatic stone-tissue detection system. Basic in-vitro studies.
Eur J Gastroenterol Hepatol.
1997;
9
563-568
-
12
Kim T H, Oh H J, Choi C S. et al .
Clinical usefulness of transpapillary removal of common bile duct stones by frequency doubled double pulse Nd:YAG laser.
World J Gastroenterol.
2008;
14
2863-2866
-
13
Manner H, Enderle M D, Pech O. et al .
Second-generation argon plasma coagulation: two-center experience with 600 patients.
J Gastroenterol Hepatol.
2008;
23
872-878
-
14
Mathur P N, Wolf K M, Busk M F. et al .
Fiberoptic bronchoscopic cryotherapy in the management of tracheobronchial obstruction.
Chest.
1996;
110
718-723
-
15
Hetzel M, Hetzel J, Schumann C. et al .
Cryorecanalization – A new approach for the immediate management of acute airway obstruction.
J Thorac Cardiovasc Surg.
2004;
127
1427-1431
-
16
Penchev R D, Kjossev K T, Losanoff J E.
Application of a new water jet apparatus in open hepatobiliary surgery: hepatic resection, cholecystectomy, common bile duct lavage.
Int Surg.
1997;
82
182-186
-
17
Piek J, Wille G, Warzok R. et al .
Waterjet dissection of the brain: experimental and first clinical results. Technical note.
J Neurosurg.
1998;
89
861-864
-
18
Shekarriz H, Shekarriz B, Kujath P.
Hydro-jet-assisted laparoscopic cholecystectomy: a prospective randomized clinical study.
Surgery.
203;
133
635-640
-
19
Gemmel C, Weickert U, Eickhoff A. et al .
Successful treatment of gallstone ileus (Bouveret’s syndrome) by using extracorporal shock wave lithotripsy and argon plasma coagulation.
Gastrointest Endosc.
2007;
65
173-175
-
20
Farin G, Grund K E.
Technology of argon plasma coagulation with particular regard to endoscopic applications.
Endosc Surg Allied Technol.
1994;
2
71-77
-
21
Lundberg B.
Thermal properties of systems containing cholesteryl esters and triglycerides.
Acta Chem Scand B.
1976;
30
150-156
-
22
Cesarani F, Gandini G, Righi D. et al .
Use of a high-frequency pulsed hydro jet in the percutaneous treatment of biliary tract calculi.
Radiol Med.
1988;
76
453-457
-
23
Wu Y W, Jian Y P, Liang J S. et al .
The treatment of intrahepatic calculosis by applying helix hydro-jet lithotripsy under video choledochoscope: a report of 30 cases.
Langenbecks Arch Surg.
2006;
391
355-358
A. EickhoffMD
Department of Interdisciplinary Endoscopy
University Hospital Hamburg-Eppendorf
Martinistr. 52
D-20254 Hamburg
Fax: +49-621-5034114
Email: a.eickhoff@uke.uni-hamburg.de
