MANAGEMENT OF GIANT COMMON BILE-DUCT STONES IN HIGH-RISK PATIENTS USING A COMBINED TRANSHEPATIC AND ENDOSCOPIC APPROACH

BACKGROUND: Endoscopic sphincterotomy (EST) for removing common bile d uct stones is regarded as the safest and most successful method, parti cularly in patients with a high surgical risk. However, giant immobile stones still continue to present a therapeutic problem, METHODS: In o ur 12 patients, when endoscopic sphincterotomy and lithotomy proved to be unsuccessful a transhepatic choledochoscopic lithotomy was attempt ed.RESULTS: The stones were fragmented using choledochoscopic electroh ydraulic lithotripsy and then were completely removed through both the transhepatic route and an EST opening in all 12 patients. The number of sessions required for these choledochoscopic procedures combined wi th EST was fewer than that required for only a transhepatic approach ( 2.5 +/- 1.3 versus 3.2 +/- 1.2), which thus resulted in a shorter hosp ital stay. Minor complications occurred in three patients with bleedin g (two from the bile duct, one from the EST opening) and in two with p ostprocedure chills and fever. CONCLUSIONS: A combined lithotomy throu gh duodenoscopic and choledochoscopic approaches is considered to be a n efficient method for removing giant biliary calculi in patients who are not successfully treated by an ordinary duodenoscopic lithotomy. ( C) 1997 by Excerpta Medica, Inc.