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Kiichi TamadaM.D.
Department of Gastroenterology
Jichi Medical School
Yakushiji
Tochigi 329-0498
Japan
Fax: + 81-285-44-8297
Email: tamadaki@jichi.ac.jp
Mailbox
Readers' comments (maximum 200 words, no illustrations) on published topics are welcome, and appear here. Readers are also invited to suggest topics of interest to The Expert Approach committee. All correspondence should be addressed to R. Lambert, M.D., preferably by email. Address: International Agency for Research on Cancer, 150 cours Albert Thomas, Lyon 693 72 cedex, France. Fax: +33-4-7273-8650, email: lambert@iarc.fr.
Comment on: Leung JW, Neuhaus H, Chopita N: Mechanical lithotripsy in the bile duct. Endoscopy 2001; 33: 800–804
To undertake therapeutic biliary endoscopy without access to mechanical lithotripsy is akin to taking a 1000 km driving tour in a convertible: you only need the top up when it is raining/snowing/cold/or the weather is otherwise inclement. In other words, you can perform ERCP perfectly well without a mechanical lithotriptor — most of the time. Until you need it. And then it becomes the roof of the convertible.
Or, you have alternatives for large calculi: stents or nasobiliary drains to bypass the stones; dissolution agents, either oral (ursodeoxycholic acid) or intra-ductal (mono-octanoin, ? methyl-tert-butyl ether); surgery; or other forms of lithotripsy (electrohydraulic, laser, or extracorporeal shock wave lithotripsy).
These latter forms of stone fragmentation are considerably more resource intensive and expensive than mechanical lithotripsy and application of the dissolution agents is, at times, equivalent to placing a rock into a glass of water and awaiting its ultimative but inevitably slow dissolution. Nor will stents or drains help you with a basket impaction or be satisfactory long-term therapy for any but the very infirm patient.
Drs. Leung, Neuhaus, and Chopita put mechanical biliary lithotripsy into perspective in this article, truly emphasizing the Expert Approach and the benefits and limitations of the various available technologies and application techniques. For those of us immersed in the care of patients with pancreaticobiliary disorders, knowledge of these lithotriptors is as essential as knowing that a patient has an allergy to an antibiotic or a bleeding diathesis. How does one disimpact a stone without access to a Soehendra lithotriptor? Anwer: don't impact it in the first place, something easier said than done. How does one pull a sharply angulated, 2 cm stone through a 1 cm distal bile duct without some form of fragmentation, usually with the through-the-scope Olympus lithotriptor, at least in our unit?
So take your 1000 km road trip and leave your lithotriptor at home. But, both you and your passengers (patients) should prepare to get sun burned, wet, and wind-blown, and colder than you ever thought possible.
Richard Kozarek, M.D., Chief of Gastroenterology,
Virginia Mason Medical Center, Seattle, WA, USA.
