体内激光碎石术与体外冲击波碎石术治疗难取性胆管结石的随机研究

Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones.

作者信息

Neuhaus H, Zillinger C, Born P, Ott R, Allescher H, Rösch T, Classen M

机构信息

Medizinische Klinik, Evangelisches Krankenhaus, Düsseldorf, Germany.

出版信息

Gastrointest Endosc. 1998 May;47(5):327-34. doi: 10.1016/s0016-5107(98)70214-7.

DOI:10.1016/s0016-5107(98)70214-7

PMID:9609422

Abstract

BACKGROUND

Endoscopic treatment modalities are well established for the removal of bile duct stones. For the small percentage of stones that are difficult or impossible to extract by conventional means, more sophisticated endoscopic techniques or associated modalities such as intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have to be applied. Little is known, however, about the relative value of these different techniques. We therefore compared endoscopic ILL with ESWL in patients with difficult bile duct stones in a prospective randomized study.

METHODS

The study included 60 patients (35 women; mean age 70+/-15 years) with bile duct stones in whom standard extraction failed (n=33) or in whom the papilla was not accessible, thus requiring percutaneous access (n=27). They were randomized to receive ESWL under fluoroscopic targeting (maximum discharge number per session: 6000) or ILL using a pulsed dye laser with an automatic stone recognition system, which was mostly performed (28 of 30 cases) under cholangioscopic control. Endoscopic removal of fragments was attempted within the subsequent (ESWL) or the same (ILL) session. Failure was defined as failure to remove all ductal stones/fragments after a maximum of three lithotripsy sessions.

RESULTS

There were no statistical differences in background variables between the two groups. Bile duct clearance was achieved in 22 of 30 patients (73%) in the ESWL group and in 29 of 30 patients (97%) in the ILL group (p < 0.05). The number of treatment sessions (ESWL 3.0+/-1.3; ILL 1.2+/-0.4; p < 0.001) and the duration of treatment (ESWL 3.9+/-3.5 days; ILL 0.9+/-2.3 days; p < 0.001) were also significantly different in favor of ILL. Two minor complications occurred in each group; there was no 30-day mortality. Crossover therapy to ILL led to stone removal in seven of the eight cases in which ESWL failed, whereas ESWL fragmented the stone in the single patient in whom ILL failed.

CONCLUSIONS

ILL is more effective in the treatment of difficult bile duct stones than ESWL in terms of stone clearance rate and treatment duration.

摘要

背景

内镜治疗方式在胆管结石清除方面已得到充分确立。对于一小部分难以或无法通过传统方法取出的结石，必须应用更复杂的内镜技术或相关方式，如体内激光碎石术（ILL）和体外冲击波碎石术（ESWL）。然而，对于这些不同技术的相对价值知之甚少。因此，我们在一项前瞻性随机研究中比较了内镜ILL与ESWL治疗胆管结石困难患者的效果。

方法

该研究纳入了60例胆管结石患者（35例女性；平均年龄70±15岁），其中标准取石失败的患者有33例，或乳头无法进入因而需要经皮穿刺的患者有27例。他们被随机分为两组，一组在荧光透视引导下接受ESWL（每次治疗的最大放电次数：6000次），另一组使用带有自动结石识别系统的脉冲染料激光进行ILL，大部分ILL操作（30例中的28例）在胆管镜控制下进行。在随后的（ESWL组）或同一治疗过程中（ILL组）尝试通过内镜取出碎片。失败定义为在最多三次碎石治疗后未能清除所有胆管结石/碎片。

结果

两组患者的背景变量无统计学差异。ESWL组30例患者中有22例（73%）实现了胆管结石清除，ILL组30例患者中有29例（97%）实现了清除（p<0.05）。治疗次数（ESWL组3.0±1.3次；ILL组1.2±0.4次；p<0.001）和治疗持续时间（ESWL组3.9±3.5天；ILL组0.9±2.3天；p<0.001）也存在显著差异，ILL更具优势。每组均发生了2例轻微并发症；无30天死亡率。ESWL失败的8例患者中有7例通过交叉治疗采用ILL成功清除了结石，而ILL失败的1例患者经ESWL使结石破碎。