Ponchon T, Gagnon P, Valette P J, Henry L, Chavaillon A, Thieulin F
Department of Digestive Diseases, Hôpital Edouard Herriot, Lyon, France.
Gastroenterology. 1991 Jun;100(6):1730-6. doi: 10.1016/0016-5085(91)90676-c.
Efficacy and safety of pulsed dye laser lithotripsy was tested in 25 consecutive patients in whom bile duct stones could not be extracted after endoscopic sphincterotomy. The patients had one to six (mean, 1.8) bile duct stones (diameter, 10-35 mm; mean, 18 mm) located in the common bile duct (18 cases), the intrahepatic bile ducts (6 cases), or in a long cystic duct stump (1 case). Different approaches were tested depending on the presence of a T tube and on the localization of the bile duct stones. When a T tube was present (7 cases), the lithotripsy was performed under direct vision using a choledochoscope inserted through the T-tube tract. In 18 patients without a T tube in place, the lithotripsy was performed under fluoroscopy using a retrograde approach in case of common bile duct stones (14 cases) or under choledochoscopy using a percutaneous transhepatic approach in case of intrahepatic bile duct stones (4 cases). Fragmentation of all the bile duct stones and a complete bile duct clearance were obtained in all 11 cases with procedures performed under direct vision as compared with only 5 of 14 cases with procedures under fluoroscopic control. Moreover, 6 of the 9 failures using the latter approach were offered another session using a choledochoscope inserted through a percutaneous transhepatic tract and were also successfully treated. No complication related to the laser beam was noted. It is concluded that pulsed dye laser lithotripsy of bile duct stones (that are unable to be removed by standard endoscopic techniques) is safe and efficacious provided that it is performed under direct vision. Technical refinements are needed before this procedure can be reliably performed under fluoroscopy.
对25例经内镜括约肌切开术后仍无法取出胆管结石的连续患者进行了脉冲染料激光碎石术的疗效和安全性测试。这些患者有1至6枚（平均1.8枚）胆管结石（直径10 - 35毫米，平均18毫米），位于胆总管（18例）、肝内胆管（6例）或长胆囊管残端（1例）。根据T管的存在情况和胆管结石的位置采用了不同的方法。当存在T管时（7例），通过T管通道插入胆道镜在直视下进行碎石术。在18例未放置T管的患者中，对于胆总管结石（14例）采用逆行法在荧光透视下进行碎石术，对于肝内胆管结石（4例）采用经皮经肝法在胆道镜下进行碎石术。与荧光透视控制下的14例手术中仅5例相比，在直视下进行手术的所有11例患者的胆管结石均被击碎且胆管完全清除。此外，后一种方法的9例失败病例中有6例通过经皮经肝通道插入胆道镜进行了另一次手术，也成功治愈。未发现与激光束相关并发症。结论是，对于（无法通过标准内镜技术取出的）胆管结石，脉冲染料激光碎石术在直视下进行是安全有效的。在能够在荧光透视下可靠地进行此手术之前，需要技术改进。
