Management of retained bile duct stones: a prospective open trial comparing extracorporeal and intracorporeal lithotripsy.

Background: Endoscopic management of common bile duct stones has become the approach of choice, especially in patients with high surgical risk. Problems are encountered if there are large stones or a duct stenosis. For these difficult stones, shock wave technology serves as an alternative to surgical intervention.
Methods: A total of 125 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected and treated either by extracorporeal piezoelectric lithotripsy (ESWL, n = 79) or intracorporeal electrohydraulic lithotripsy (EHL, n = 46). The average age of our patients was 70 years.
Results: In the ESWL group visualization of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%); stones could be fragmented in 68 patients. The biliary tree could then be completely freed of calculi in 62 of 79 patients, a success rate of 78.5%. In the EHL group, stones were successfully fragmented in 38 of 46 patients; 34 patients (74%) eventually became stone free. Thirty-day mortality was zero in both groups. Combined treatment including ESWL, EHL, and intracorporeal laser lithotripsy was finally successful in 118 patients (94%).
Conclusions: Endoscopic management in combination with the lithotripsy techniques described can be recommended as the method of choice for treating difficult common bile duct stones. A success rate of almost 100% and a mortality rate of 0% is now the established standard, even in elderly and unstable patients.