Tunable dye laser lithotripsy is an effective and low risk treatment in patients with bile duct stones in which transpapillary maneuvers failed. The percutaneous approach allows to introduce small caliber endoscopes (10.5 F) to fragment the calculi under vision. This technique was evaluated in 8 patients who had undergone a biliodigestive anastomosis or in whom the biliary calculi could not removed by standard retrograde treatment. Laser lithotripsy resulted in sufficient fragmentation in 7 patients. Bile duct clearance proved to be a particular problem with the percutaneous access. When a retrograde sphincterotomy is not possible an antegrade papillotomy must be attempted under fluoroscopic guidance. In bile duct strictures the implantation of expandable stents facilitates the passage of fragments and may prevent recurrent stricture and development of new stones.
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