References
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Inui K, Nakazawa S, Yoshino J, et al.
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Tamada K, Tomiyama T, Ichiyama M, et al.
Influence of biliary drainage catheter on bile duct wall thickness as measured by
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Tamada K, Ueno N, Tomiyama T, Oohashi A, et al.
Characterization of biliary strictures using intraductal ultrasonography: comparison
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Tamada K, Wada S, Ohashi A, et al.
Intraductal US in assessing the effects of radiation therapy and prediction of patency
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Kiichi TamadaM.D.
Department of Gastroenterology
Jichi Medical School
Yakushiji
Tochigi 329-0498
Japan
Fax: + 81-285-44-8297
Email: tamadaki@jichi.ac.jp
Mailbox
Readers' comments (maximum 200 words, no illustrations) on published topics are welcome,
and appear here. Readers are also invited to suggest topics of interest to The Expert
Approach committee. All correspondence should be addressed to R. Lambert, M.D., preferably
by email. Address: International Agency for Research on Cancer, 150 cours Albert Thomas,
Lyon 693 72 cedex, France. Fax: +33-4-7273-8650, email: lambert@iarc.fr.
Comment on: Leung JW, Neuhaus H, Chopita N: Mechanical lithotripsy in the bile duct.
Endoscopy 2001; 33: 800–804
To undertake therapeutic biliary endoscopy without access to mechanical lithotripsy
is akin to taking a 1000 km driving tour in a convertible: you only need the top up
when it is raining/snowing/cold/or the weather is otherwise inclement. In other words,
you can perform ERCP perfectly well without a mechanical lithotriptor — most of the
time. Until you need it. And then it becomes the roof of the convertible.
Or, you have alternatives for large calculi: stents or nasobiliary drains to bypass
the stones; dissolution agents, either oral (ursodeoxycholic acid) or intra-ductal
(mono-octanoin, ? methyl-tert-butyl ether); surgery; or other forms of lithotripsy
(electrohydraulic, laser, or extracorporeal shock wave lithotripsy).
These latter forms of stone fragmentation are considerably more resource intensive
and expensive than mechanical lithotripsy and application of the dissolution agents
is, at times, equivalent to placing a rock into a glass of water and awaiting its
ultimative but inevitably slow dissolution. Nor will stents or drains help you with
a basket impaction or be satisfactory long-term therapy for any but the very infirm
patient.
Drs. Leung, Neuhaus, and Chopita put mechanical biliary lithotripsy into perspective
in this article, truly emphasizing the Expert Approach and the benefits and limitations
of the various available technologies and application techniques. For those of us
immersed in the care of patients with pancreaticobiliary disorders, knowledge of these
lithotriptors is as essential as knowing that a patient has an allergy to an antibiotic
or a bleeding diathesis. How does one disimpact a stone without access to a Soehendra
lithotriptor? Anwer: don't impact it in the first place, something easier said than
done. How does one pull a sharply angulated, 2 cm stone through a 1 cm distal bile
duct without some form of fragmentation, usually with the through-the-scope Olympus
lithotriptor, at least in our unit?
So take your 1000 km road trip and leave your lithotriptor at home. But, both you
and your passengers (patients) should prepare to get sun burned, wet, and wind-blown,
and colder than you ever thought possible.
Richard Kozarek, M.D., Chief of Gastroenterology,
Virginia Mason Medical Center, Seattle, WA, USA.
