Use of pneumatic lithotripsy for managing difficult CBD calculi

International Journal of Surgery 9 (2011) 59e62 Contents lists available at ScienceDirect International Journal of Surgery journal homepage: www.theijs.com Use of pneumatic lithotripsy for managing difficult CBD calculi Syed Javid Farooq Qadri*, Muneer Khan, Naveed Khan Department of Minimal Access Surgery, Institute of Kidney and Urological Disease Research Center, Sonwar, Srinagar, India a r t i c l e i n f o a b s t r a c t Article history: Received 20 July 2010 Received in revised form 22 August 2010 Accepted 26 August 2010 Available online 16 September 2010 Introduction: About 7e12% of patients who harbor gallbladder calculi concomitant common bile duct (CBD) calculi are present. The treatment of gallbladder calculi has standardized in the form of laparoscopic cholecystectomy but management of CBD calculi is still evolving. Endoscopic removal of CBD calculi <2 cm in diameter is successful in 90e100% of cases but patients harboring stones >2 cm in diameter high failure rates can be seen. Traditionally, laparoscopically one can achieve success rate comparable to endoscopic surgery but large and impacted calculi may cause failures. If one uses pneumatic lithotripsy during laparoscopic management of CBD calculi one can achieve 100% stone clearance irrespective of size, degree of hardness and impaction. This study evaluates the feasibility of using pneumatic lithotripsy for CBD calculi. To our knowledge this is the 1st reported series of using pneumatic lithotripsy for CBD calculi. Material and methods: From June 2002 to June 2010 96 laparoscopic CBD explorations (LCBDE) were done for CBD calculi. Patients having choledocholithiasis with CBD diameter of >10 mm were taken for LCBDE while in patients with CBD diameter of <10 mm were referred for endoscopic clearance. Additionally ERCP failure cases were also subjected to LCBDE. Rigid nephroscope was used for LCBDE and usually calculi were removed by forceps only. In patients having large, hard &/or impacted calculi pneumatic lithotripsy were used for fragmentation. Results: Out of the 96 patients in 12 (12.5%) cases pneumatic lithotripsy was used for stone fragmentation. Out of these 12 cases 5 (41.6%) were ERCP failure cases. At a mean hospital stay of 2.5 days 100% stone clearance was achieved in all cases with no perioperative complication. Conclusion: The present study shows how successfully pneumatic lithotripsy can be used to fragment large, hard &/or impacted CBD calculi. Pneumatic lithotripsy being user friendly easily available can reliably fragment CBD calculi in one session. Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. Keywords: CBD calculi Endoscopic removal Laparoscopic CBD exploration Pneumatic lithotripsy 1. Introduction Gallbladder calculi and common bile duct (CBD) calculi affect significant proportion of human population. About 7e12% cases of gallbladder calculi concomitant common bile duct (CBD) calculi are present.1,2 In 85e90% of cases bile duct calculi can be successfully removed endoscopically by balloon catheter and basketing after sphincterotomy3 but in patients harboring larger stones >2 cm diameter high failure rates are seen even after using mechanical lithotripsy.4,5 Laparoscopic management of CBD calculi is a valid option. It offers cure of gallbladder calculi and CBD calculi in one session and additionally large hard or even impacted stones pose * Corresponding author. R/O Riyazat-taing Khanyar, Srinagar, J&K 190003, India. Tel.: þ91 0194 2456086/09419011913. E-mail address: [email protected] (S.J. Farooq Qadri). no problem as one can use pneumatic lithotripsy very successfully for fragmenting all types and sizes of stones and thus ensure 100% stone clearance unlike endoscopic clearance. The present study is about evaluating the efficacy of pneumatic lithotripsy for managing difficult CBD stone during laparoscopic common bile duct exploration (LCBDE). To our knowledge this is the 1st reported series of using pneumatic lithotripsy for common bile duct stones. 2. Material and methods At our center we are managing patients with ductal calculi in two ways. Patients harboring CBD stones with CBD diameter of <10 mm are referred for endoscopic clearance of stones followed by laparoscopic cholecystectomy (LC). In patients where CBD diameter is >10 mm single stage LC with transductal laparoscopic CBD exploration (LCBDE) with rigid nephroscope is performed. Additionally all patients referred from the department of gastroenterology as ERCP failure cases are subjected to LCBDE. During LCBDE usually stones are removed by using forceps only but in case of large, hard or impacted CBD stones pneumatic lithotripter is used for stone fragmentation. 1743-9191/$ e see front matter Ó 2010 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ijsu.2010.08.009 60 S.J. Farooq Qadri et al. / International Journal of Surgery 9 (2011) 59e62 Fig. 3. Calculus fragmented with lithoclast. Fig. 1. (a) Richard Wolf Lithoclast, (b) Lithoclast hand piece and probe. 2.1. Technique The procedure is done under general anesthesia with endotracheal intubation. Position of ports is identical as used for LC viz 10 mm at umbilicus for 30 telescope, 10 mm epigastric port and two 5 mm ports one in midclavicular line 3e4 cm below the costal margin and other in anterior axillary line 2e4 cm below midclavicular port. The cystic duct is dissected and clipped. Longitudinal choledochotomy 1e1.5 cm in size in supraduodenal CBD is made by cold endoknife and 24Fr rigid nephroscope (Richard Wolf, Germany) which is connected to second imaging system is passed through the 10 mm epigastric port (ENDOPATHÒ XcelÔ Trocar) under laparoscopic vision into the CBD. Any stone seen is retrieved using the biprong or triprong forceps. Large firm stones can be crushed by forceps only and fragments then retrieved. In case of large, hard or impacted stones pneumatic lithotripter(Richard Wolf, Germany) (Fig. 1a,b) is used for fragmentation. The probe of the lithotripter is passed through working channel of nephroscope and then targeted towards the stone (Fig. 2) and then fragmented (Fig. 3). At no point probe is allowed to tough the wall of the CBD and the probe is aligned in such a way so that the force generated by it is not Fig. 2. Lithoclast probe in direct contact with the calculus. directed towards the CBD wall as imperfect use of the pneumatic lithotripter can cause CBD damage/perforation. Fragments are removed by forceps (Fig. 4). Total proximal (Fig. 5) and distal (Fig. 6) CBD clearance is ensured under vision of nephroscope. After doing complete clearance of the CBD choledochotomy site is closed by 4e0 Vicrl using continuous locking suturing technique. T-tube is placed in those cases in whom stone load in the CBD resulted in prolonged and extensive manipulation within the CBD and/or lithotripter was used for stone fragmentation. This is followed by completion laparoscopic cholecystectomy and placement of 14 F drain in the sub hepatic space through the 5 mm port in midaxillary line. If t-tube has been used it is passed through the midclavicular 5 mm port. Nasogastric tube is placed for first 24 h. The drain is removed as soon as its output decreases to less than 20 ml per 24 h. T-tube cholangiogram is done by postoperative day 7e10 and removed the next day if normal. Video clip of the procedure is attached to the manuscript. Supplementary information associated with this article can be found in the online version, at doi:10.1016/j.ijsu.2010.08.009. 3. Results From June 2002 to June 2010, 96 laparoscopic CBD explorations were done for CBD calculi. 13 (13.54%) Patients were ERCP failure Fig. 4. Forceps removing stone fragments. 61 S.J. Farooq Qadri et al. / International Journal of Surgery 9 (2011) 59e62 Table 1 Details of patients in whom pneumatic lithotripsy was used during LCBDE. Fig. 5. Total proximal clearance. cases and in 83 (86.46%) cases LCBDE was done as a primary procedure. The mean age of the patients was 35.6 years (range: 19e73 years), 72 (75%) were females and 24 (25%) males. 86 (89.6%) Patients had both gallbladder stones and CBD stones while 10 (10.4%) had only CBD stones. 12 (12.5%) patients had solitary CBD calculus while 84 (87.5%) patients had multiple CBD calculi. The mean CBD diameter was 16.2 mm (range 10e41 mm). One (1.04%) patient was converted to open due to dense adhesions. Choledochotomy was managed by primary closure in 69 (71.88%) patients, closure over t-tube in 26 (27%) and by choledochoduodenostomy in 1 (1.04%). Postoperative bile leak was seen in 2 (2.08%) patients. The mean operative time was 87.4 min (range 53e155 min). The mean hospital stay was 3.9 days (range: 2e19). One (1.08%) patient had residual stone which was managed by ERCP. In 12 (12.5%) cases pneumatic lithotripsy was used to fragment the stone (Table 1). 5 (41.6%) Patients were ERCP failure cases and in all patients at least two attempts of endoscopic removal were tried and all patients had stent in situ. Their stents were also removed at the time of CBD exploration. Mean operative time was more in this subset of patients (105 min) due to the use of pneumatic lithotripsy and the retrieval of fragments. T-tube was used in all patients to Fig. 6. Total distal clearance. Variable Result No of cases ERCP failure case Mean age, years Male/Females Mean CBD diameter, mm Mean stone diameter, mm Impacted stones Coexisting gallstones Choledochotomy Mean operative time, min Mean hospital stay, days Perioperative complications Residual stones Success 12 5 (41.6%) 47 (37e52) 4 (33.34%)/8 (66.66%) 21.4 (18e41) 18.4 (14.5e36) 4 (33.34%) 12 (100%) T-tube 12 (100%) 105 (95e155) 2.5 (2e5) 0 0 12 (100%) manage the choledochotomy keeping in view the use of pneumatic lithotripsy. No case of bile leak was seen in this patient group and postoperative t-tube cholangiogram were free of any residual CBD calculi. 4. Discussion The management of CBD calculi involves the use of ERCP  S at most of the gastroenterology centers. This technique has high sensitivity and specificity of >95% in diagnosing CBD calculi.2 CBD calculi are successfully treated by balloon catheter and basket in 85e90% of patients.3,6 Unfortunately using standard endoscopic methods of stone removal a failure rate of 5e10% can be seen because either stone is too large or impacted. With the use of mechanical lithotripsy the success rate can be improved but factors which complicate removal of CBD stones by basket and balloon catheter may cause failure of mechanical lithotripsy as well.7 Shaw et al. in a multi-center study showed the success rate for calculi <2 cm in diameter to be 90e100% but decreases to 68e83% for calculi with diameter of 3 cm or more.8 Garg et al. over a 4-year period achieved a success rate of only 79% for removing CBD calculi even after using mechanical lithotripsy.9 It has been consistently shown that the failure rate is high even with the use of mechanical lithotripsy for stones >2 cm in diameter.4,5 Laparoscopic management of CBD stones is gaining enthusiasm in the surgical fraternity. With the introduction of use of instruments like rigid nephroscope in LCBDE, management of CBD stones has taken a new and important turn. Large and impacted stones are no problem now. One can use easily available pneumatic lithotripter for fragmenting large hard impacted CBD stones with no added morbidity. Unlike ERCP  S, LCBDE can manage choledocholithiasis and cholelithiasis in single session. Hospital stay is short and fewer resources are involved and over all is cost effective than staged ERCP  S and LC.10,11 Traditionally use of flexible choledochoscope was involved in LCBDE. It had disadvantage of having narrow working channel through which stout instruments could not be negotiated and thus large and impacted CBD stones could not be easily cleared. One needs costly equipment like laser and electrohydraulic lithotripsy which are not usually available at most of the centers to manage large impacted CBD stones with varied success. Fortunately this shortcoming has been overcome with the use of rigid nephroscope for LCBDE.12 This instrument is usually available at all surgical centers. It is robust, has large working channel and vision is excellent. One can pass stout forceps through it to remove calculi. Importantly one can use pneumatic lithotripter which is also usually available at all surgical centers to break large and impacted calculi and thus ensure 100% stone clearance irrespective 62 S.J. Farooq Qadri et al. / International Journal of Surgery 9 (2011) 59e62 of size, hardness or degree of impaction of the stone. Stone propulsion which is commonly seen in pneumatic lithotripsy of ureteric stone is not seen in CBD. Pneumatic lithotripsy is based on a jackhammer principle.13 A projectile in the hand piece is propelled by compressed air through the probe. The compressed air originates from a small generator that is connected to a dry, clean air supply. The ballistic energy produced is conveyed to the probe base at a rate of 12 Hz.14 Continued impaction of the probe tip against the stone results in stone breakage once the tensile forces of the calculus are overcome.15 Piergiovanni and colleagues16 studied the four modalities of contact lithotripsy viz electrohydraulic, pneumatic, laser and ultrasonic and their associated effects on the bladder and ureteral wall. Piergiovanni and others found the lithoclast to produce the least microscopic and macroscopic damage to the urothelium.15,16 Meyer17 histologically demonstrated absence of detectable urothelial damage with up to 20 direct lithotripter shocks to the ureteral wall. In a Duke University study, Teh and colleagues14 provided a more standardized, scientific, and statistical evaluation of the pneumatic lithotripsy. Teh and colleagues14 demonstrated lower fragmentation indices (that is, better fragmentation efficiency) for the pneumatic lithotripter. Histologic examinations, noted 2 weeks after treatment, revealed ureteral specimens without any significant urothelial injury. The results of these studies encourage one to use pneumatic lithotripsy in CBD as well. Pneumatic lithotripsy has the added benefit of better stone targeting and visualization than is possible with the laser. Rapid flashes of light emanating from the laser and visually obscuring protective eyewear may interfere with targeting.18 Another advantage of pneumatic lithotripsy is the ability to crack harder stones.13,14,18 Our experience with the use of pneumatic lithotripsy is very encouraging and seems to be safe and highly effective. We achieved 100% stone clearance in all patients and there was no appreciable macroscopic CBD wall damage or any complication in the follow up. 5. Conclusion The results of the present study shows how successful one can use pneumatic lithotripsy for fragmenting large, hard impacted CBD calculi without any complications. Pneumatic lithotripsy being easily available, user friendly, relatively inexpensive, causes no endothelial damage, having high reliability for single session stone fragmentation can become the next standard of care for fragmenting difficult large, hard &/or impacted calculi in dilated CBD during laparoscopic CBD exploration. Conflict of interest The authors have no conflict of interest. Funding None. Ethical approval None declared. References 1. Adamek HE, Maier M, Jakobs R, Wessbecher FR, Neuhauser T, Riemann JF. Management of retained bile duct stones: a prospective open trial comparing extracorporeal and intracorporeal lithotripsy. Gastrointest Endosc 1996;44:40e7. 2. Bergman JJ, Rauws EA, Tijssen JG, Tytgat GN, Huibregtse K. Biliary endoprostheses in elderly patients with endoscopically irretrievable common bile duct stones: report on 117 patients. Gastrointest Endosc 1995;42:195e201. 3. Binmoeller KF, Brückner M, Thonke F, Soehendra N. 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