[Endoscopic laser lithotripsy for difficult calculi after unsuccessful extracorporeal shock wave lithotripsy]. / Litotripsia endoscópica à laser em cálculos difíceis não responsivos à litotripsia extracorpórea por ondas de choque.

INTRODUCTION: More than 97% of common bile duct stones can be successfully managed by endoscopic papillotomy, mechanical lithotripsy and extracorporeal shock-wave lithotripsy. In this study, we evaluate the role of laser lithotripsy after failure of the above mentioned endoscopic methods. PATIENTS AND METHODS: Eighteen patients (15F, 3M; median age = 69 (28-83) years) were treated by endoscopic laser lithotripsy after ESWL failure. We employed a Rhodamine-6 G laser with a stone-tissue recognizing system. The laser fibers were cholangioscopically (direct vision) or blindly (under plain fluoroscopic control) placed. RESULTS: Seventeen patients were treated endoscopically and one was successfully managed percutaneously after failure of the transpapillary approach. Fourteen (78%) were stone-free after a mean of 1.56 laser therapy sessions alone. Two additional patients were successfully managed after partial fragmentation with combined treatment (mechanical lithotripsy: n = 1, electrohydraulic lithotripsy: n = 1). Overall, 89% of the patients were freed from their calculi. Cholangitis occurred once and the mortality was zero. CONCLUSIONS: We conclude that laser lithotripsy is an effective and safe treatment alternative in a highly selected patient population with difficult bile duct stones and considerable surgical risk.