간외담관결석의 비수술적 치료: 치료방법의 선택

Abstract

Background: With the greater improvement in endoscopic techniques and lithotripsy devices, the extrahepatic bile duct stones can be managed preferentially by non-surgical modality including endoscopic sphincterotomy(EST). But 10-15% of extrahepatic bile duct stones cannot be removed by non-surgical modality. This study is conducted to evaluate the cause of failure of endoscopic treatment of extrahepatic bile duct stones and its risk factors and decide the guide an index to choice of management modality according to risk factors. Method: We retrospectively reviewed the clinical records of 387 of patients with extrahepatic bile duct stones who were managed by non-surgical modality including EST, mechanical lithotripsy(ML), electrohydrauric lithotripsy(EHL), extracorporeal shock wave lithotripsy(ESWL), endoscopic balloon sphincteroplasty(EBS) between Jan. 1986 and June 1996. Result: The extrahepatic bile duct stones were removed successfully by EBS(10 cases), EST only(26 cases), EST with ballon & basket(252 cases), mechanical lithotriptor(15 cases), and peroral cholangioscope with EHL(5 cases) in 308 cases. The success rate of transpapillary approach for extrahepatic bile duct stones removal was 79.6%. In the remaining 79 cases extrahepatic bile duct stones were removed in 21 cases by ESWL(14 cases) or PTCS with EHL(7 cases). The overall success rate of non-surgical treatment for extrahepatic bile duct stone removal was 85.0%(329/387 cases). The causes of failure for stones removal by transpapillary approach were the failure of EST in 25 cases, failure to capture of stones by basket in 10 cases, large stone in 30 cases, impacted stone in 14 cases. Statistically significant risk factor for failure of extrahepatic bile duct stones removal by transpapillary approach was only size of stones. stones removal was tried by EBS, EST only, and EST with balloon & basket in 96.5% of cases with size of stones less than 20 mm(330/342 cases) but was tried by ML or EHL in 44.4% of cases(20/45 cases) with size of stones more than 20 mm. Complication associated with the procedure were bleeding in 16 cases, acute pancreatitis in 10 cases, perforation in 2 cases, cholangitis/sepsis in 1 case, and acute cholecystitis in 1 case. No mortality was noted. Conclusions: In the cases with size of stone less than 11 mm EBS maybe useful and in size of stone less than 20 mm EST with basket and balloon is more useful to remove the extrahepatic bile duct stones. But stone fragmentation by ML, ESWL, EHL as additional method should be considered in the cases with size of stone more than 20 mm.