Abstracts
1997 Digestive Disease Week

Treatment of primary intrahepatic stones with a holmium laser.

P Shamamian, M Grosso*, A Guth, T Diflo, SG Marcus, GF Coppa, K Eng. SA Localio Laboratory for General Surgery Research and Department of Urology*, New York University School of Medicine, New York, NY.

Primary intrahepatic stones (PHS), also known as cholangiohepatitis causes recurrent cholangitis and eventually leads to hepatic failure and death. No commonly used therapy has been demonstrated to adequately clear the intrahepatic ducts of calculi and prevent recurrent sepsis. Present therapy consisting of biliary enteric bypass and hepatic resection is fraught with complications and treatment failures. Significant advances in fiberoptic endoscopy allow exploration of the intrahepatic biliary ducts and the introduction of endoscopic accessories such as baskets, dilators and laser fibers. We have adapted these advances in biliary endoscopy with a Holmium laser lithotripter to treat PHS. The safety and efficacy of Holmium laser lithotripsy for urinary tract calculi has been demonstrated. The Holmium laser is ideal for PHS as it provides sufficient energy to "vaporize" calculi, with minimal risk to adjacent tissue in experienced hands. To date ten patients have been treated with laser lithotripsy (LLT). Access for LLT was obtained via percutaneous biliary drains (5) or surgically placed T-Tube tracts (5). Biliary drainage was established by biliary enteric bypass (8) or endoscopic sphincterotomy (2). Five patients had prior surgical therapy including two with left hepatic resections. With thorough intrahepatic endoscopy, bilateral calculi were found in all patients, demonstrating the futility of hepatic resection for this desease. At least three LLT treatments were required for clearance of calculi, and no patient with complete clearance has represented with biliary sepsis. All segments of the intrahepatic ducts were accessed for LLT and the Holmium laser was able fragment calculi regardless of chemical composition. No patient required liver resection and there were no deaths following LLT. Three patients had post LLT tachyarrhythmias and one patient developed a subcapsular hematoma. In 24 patients treated by other methods at our institution prior to the development of LLT, there were seven major complications, 10 liver resections and one death. It is therefore clear that LLT should be the preferred approach to PHS in order to provide stone clearance, preserve hepatic parenchyma and prevent recurrent sepsis.