Ponchon T, Martin X, Barkun A, Mestas J L, Chavaillon A, Boustière C
Department of Hepatogastroenterology, Hôpital Edouard Herriot, Lyons, France.
Gastroenterology. 1990 Mar;98(3):726-32. doi: 10.1016/0016-5085(90)90295-c.
In 19 patients, extraction of bile duct stones through the papilla using a Dormia basket or a mechanical lithotripter was not possible following endoscopic sphincterotomy. After the insertion of a nasobiliary drain, extracorporeal lithotripsy was performed with intravenous sedation using an ultrasonographic stone localization system. The number and location of stones were first determined by retrograde cholangiography. At the time of lithotripsy, saline was injected in the bile ducts to modify the acoustic impedance of tissues surrounding the stones, and subsequent ultrasonography was effective in localizing all stones present in 4 of 5 (80%) patients with intrahepatic stones, and 13 of 14 (93%) with common bile duct stones. In 10 patients (53%), fragmentation was satisfactory and the bile ducts were cleared completely. The mean single stone diameter was significantly smaller in successful cases of fragmentation compared with failures (22.8 +/- 6.6 mm vs. 40 +/- 10 mm). The results in patients with multiple stones were significantly worse than those in patients with single stones of similar size (25% vs. 100% successful fragmentation). Reasons for this difference in results included the small size of the focal area and the reduced ability of ultrasonography (1) to adequately visualize multiple calculi individually and (2) to assess the degree of stone destruction. Care was taken to first await the resolution of infection or the correction of coagulation abnormalities when present; no morbidity following extracorporeal lithotripsy was observed. Despite its 3-step approach (endoscopic sphincterotomy, lithotripsy, and endoscopic extraction), the need for only intravenous sedation and the absence of patient immersion in water render this technique attractive for elderly and frail patients.
19例患者在内镜下括约肌切开术后，无法使用多尔米亚网篮或机械碎石器经乳头取出胆管结石。插入鼻胆管引流管后，使用超声结石定位系统在静脉镇静下进行体外碎石。结石的数量和位置首先通过逆行胆管造影确定。在碎石时，向胆管内注入生理盐水以改变结石周围组织的声阻抗，随后的超声检查有效地定位了5例肝内结石患者中的4例（80%）以及14例胆总管结石患者中的13例（93%）的所有结石。10例患者（53%）结石破碎效果满意，胆管完全清除。成功破碎结石的病例中，单个结石的平均直径明显小于未成功的病例（22.8±6.6mm对40±10mm）。多颗结石患者的结果明显比类似大小单颗结石患者的结果差（结石成功破碎率分别为25%和100%）。结果存在差异的原因包括聚焦区域小以及超声检查能力下降，（1）无法充分单独清晰显示多颗结石，（2）无法评估结石破坏程度。如有感染或凝血异常，首先等待其缓解或纠正；未观察到体外碎石术后出现并发症。尽管采用了三步法（内镜括约肌切开术、碎石术和内镜取出术），但仅需静脉镇静且患者无需浸入水中，使得该技术对老年和体弱患者具有吸引力。
