Extracorporeal shock wave lithotripsy for bile duct stones: an Australian experience

Choledocholithiasis requires prompt therapy, particularly if complicated by ascending cholangitis. Endoscopic sphincterotomy with balloon and basket extraction clears the bile duct in 90% of patients. Failure is usually associated with large stones, that is, greater than 2 cm. Until recently such patients would have required surgical intervention. In 1986 St Vincent's Hospital installed a Dornier HM3 Lithotriptor to be used for both urinary tract and bile duct calculi. A retrospective analysis of patients referred for extracorporeal shock wave lithotripsy (ESWL) to bile duct stones was performed. There were 47 patients (28 female, 19 male) with an average age of 76 years. Twenty-two patients had a single stone with a mean diameter of 2.4 cm and 25 had multiple stones. In two patients the stone was not able to be visualized, so ESWL could not be performed. Complete stone clearance was achieved without further intervention in 13 patients, and in a further 23 after endoscopic extraction of fragments. In five patients only partial duct clearance was achieved. However, this provided palliation and enabled the patient to be discharged. Surgical intervention was required in the remaining four cases. Overall success rate was 80% with a further 11% being palliated with improved biliary drainage. There were no serious adverse effects from ESWL. All patients were discharged from hospital. Mortality at 30 days was 4.7% and at 6 months was 19.4%. One patient succumbed to ascending cholangitis 22 weeks post-ESWL (2.7%). All other deaths were unrelated to ESWL or biliary disease. We conclude that ESWL is a safe and effective treatment for bile duct stones not amenable to endoscopic extraction.