Neuhaus H, Hoffmann W, Zillinger C, Classen M
II Medical Department, Technical University of Munich, Germany.
Gut. 1993 Mar;34(3):415-21. doi: 10.1136/gut.34.3.415.
Biliary laser lithotripsy was performed under direct visual control in 35 consecutive patients not amenable to routine endoscopy. The patients had 1-50 (median 1) bile duct stones with the greatest diameter of the largest stone being 9-42 mm (median 20 mm). Conventional endoscopic treatment had failed because of an inaccessible papilla (16 patients), biliary strictures (seven patients), and impaction or large size of calculi (12 patients). Twelve patients, depending on their anatomical condition, underwent peroral cholangioscopy by means of a mother-babyscope system. Percutaneous cholangioscopy was initially carried out in 23 patients, 7-20 days (median 10 days) after creation of a transhepatic fistula. Pulsed dye laser (32 patients) or alexandrite laser (three patients) lithotripsy was applied under an appropriate direct visual control in all cases. Complete stone disintegration succeeded in 33 of 35 patients. All resultant fragments passed the papilla within a mean number of 1.3 treatment sessions. Peroral cholangioscopic lithotripsy failed in two cases. One patient successfully underwent percutaneous laser treatment and the other patient was referred to surgery. Fever, temporary haemobilia, or a subcapsular liver haematoma were seen in a total of eight patients during establishment of the cutaneobiliary fistula. A 95 year old patient who had been admitted with septic cholangitis died because of cardiorespiratory failure 5 days after bile duct clearance. It is concluded that laser lithotripsy performed under a direct visual control is an effective and safe procedure for the non-surgical treatment of difficult bile duct stones. Ductal clearance can usually be achieved in a single treatment session when the papilla and the stones are accessible by the peroral route. Percutaneous cholangioscopic lithotripsy is more time consuming but highly effective even in patients with a difficult anatomy, bile duct strictures, or intrahepatic calculi. This approach should be limited, however, to cases not amenable to retrograde procedures because the creation of the cutaneobiliary fistula is not without risks.
对35例不适合常规内镜检查的患者在直视控制下进行了胆道激光碎石术。这些患者有1至50枚（中位数为1枚）胆管结石，最大结石直径为9至42毫米（中位数为20毫米）。由于乳头难以接近（16例患者）、胆管狭窄（7例患者）以及结石嵌顿或体积过大（12例患者），常规内镜治疗失败。12例患者根据其解剖情况，通过子母镜系统进行了经口胆管镜检查。23例患者在建立经肝瘘7至20天（中位数为10天）后首先进行了经皮胆管镜检查。在所有病例中，均在适当的直视控制下应用脉冲染料激光（32例患者）或翠绿宝石激光（3例患者）进行碎石术。35例患者中有33例结石完全碎裂。所有产生的碎片平均在1.3次治疗过程中通过乳头。经口胆管镜碎石术有2例失败。1例患者成功接受了经皮激光治疗，另1例患者转至外科手术。在建立皮肤胆管瘘期间，共有8例患者出现发热、暂时性胆道出血或肝包膜下血肿。1例因化脓性胆管炎入院的95岁患者在胆管清除术后5天因心肺功能衰竭死亡。结论是，在直视控制下进行的激光碎石术是一种治疗难处理胆管结石的有效且安全的非手术方法。当经口途径可到达乳头和结石时，通常单次治疗即可实现胆管清除。经皮胆管镜碎石术耗时更长，但即使对于解剖结构复杂、胆管狭窄或肝内结石的患者也非常有效。然而，这种方法应仅限于不适合逆行手术的病例，因为建立皮肤胆管瘘并非没有风险。
