Born P, Neuhaus H, Classen M
II. Medizinische Klinik, Technischen Universität München, Klinikum rechts der Isar.
Z Gastroenterol. 1995 Apr;33(4):202-8.
After failure of extracorporeal shockwave lithotripsy (ESWL) the benefit of further nonsurgical methods for treatment of difficult bile duct stones is undetermined. Endoscopic laserlithotripsy is a promising procedure providing target application of high energy levels.
Twenty patients (median age: 81 [67-91] years) were referred for laserlithotripsy of 1-8 (median, 2) difficult bile duct stones after failure of 1-4 (median, 3) ESWL sessions. The median diameter of each of the largest stone was 22 (10-48) mm. The laser used was a pulsed rhodamine laser (wavelength: 594 nm) with an automatic cut-out system upon no stone contact. The laser fiber was positioned by means of ERCP under fluoroscopic control or by use of mini-cholangio-scopes. Laserlithotripsy was cholangioscopically performed via the percutaneous transhepatic route in 8 patients because of retrogradely inaccessible bile ducts (n = 5) or because further ERCP was refused (n = 3). All procedures were carried out under intravenous sedation and/or analgesia.
Laser lithotripsy and complete removal of fragments was achieved in 19 of the 20 patients after application of 70-25700 (median, 3310) pulses in 1.2 sessions per patient. Median duration of a single session was 70 (15-140) minutes. The procedure failed in one patient with an impacted stone at the cystic duct confluence. Cholangitis could be conservatively managed in 2 cases. No further complication was observed. The 30-day mortality rate was 0 %.
Endoscopic laserlithotripsy is an effective, a rapid and safe procedure for bile duct stones even after failure of ESWL. The results compare favorably with open surgery, particularly in view of an increased risk in a group of elderly patients.
体外冲击波碎石术（ESWL）失败后，进一步采用非手术方法治疗难治性胆管结石的益处尚不确定。内镜激光碎石术是一种有前景的方法，可实现高能级的靶向应用。
20例患者（中位年龄：81[67 - 91]岁）在1 - 4次（中位3次）ESWL治疗失败后，因1 - 8枚（中位2枚）难治性胆管结石接受激光碎石术。每枚最大结石的中位直径为22（10 - 48）mm。使用的激光是脉冲若丹明激光（波长：594 nm），在无结石接触时具有自动切断系统。激光光纤通过在荧光镜控制下的内镜逆行胰胆管造影（ERCP）或使用微型胆管镜定位。由于胆管逆行无法到达（n = 5）或患者拒绝进一步ERCP（n = 3），8例患者通过经皮经肝途径在胆管镜下进行激光碎石术。所有手术均在静脉镇静和/或镇痛下进行。
20例患者中的19例在每位患者进行1.2次治疗、应用70 - 25700次（中位3310次）脉冲后实现了激光碎石并完全清除碎片。单次治疗的中位持续时间为[15 - 140]分钟。1例患者在胆囊管汇合处结石嵌顿，手术失败。2例胆管炎患者经保守治疗后好转。未观察到其他并发症。30天死亡率为0%。
即使在ESWL失败后，内镜激光碎石术对于胆管结石也是一种有效、快速且安全的方法。其结果与开放手术相比具有优势，特别是考虑到老年患者群体风险增加的情况。
