The role of extracorporeal shock wave lithotripsy combined with endoscopic management of impacted cystic duct stones in patients with high surgical risk.

Background/aims: Cholecystoscopic lithotripsy can be an alternative procedure for the treatment of impacted cystic duct stones in patients who are high risk for surgery. Conventional methods, including electrohydraulic lithotripsy (EHL), occasionally fail due to the inability to access or capture the impacted stones in the narrow, spirally long cystic duct. Using extracorporeal shock wave lithotripsy (ESWL) may be more effective to disintegrate cystic duct stones. The aim of the study is to evaluate the role of ESWL in the endoscopic treatment of impacted cystic duct stones in patients with high operative risk.

Methodology: Eleven patients with impacted cystic duct stones who were at high risk for surgery were included in this study. All of them had had a failed initial attempt of percutaneous transhepatic cholecystoscopic lithotripsy (PTCCS-L) followed by percutaneous transhepatic cholecystostomy. Patients underwent ESWL to disintegrate cystic duct stones with endoscopic removal of fragmented stones.

Results: Complete removal of cystic duct stones was achieved in 9 of 11 patients (81.8%). One of the 9 patients (11.1%) was treated solely with ESWL, but the other 8 patients (88.9%) required cholecystoscopic removal of residual fragmented stones after ESWL. Fragmented stones passing through the cystic duct impacted in ampullary region in 3 patients after ESWL. Two patients required transpapillary removal of stones.

Conclusions: Endoscopic stone removal after ESWL for impacted cystic duct stones is a difficult and time-consuming procedure. But, it seems to be a relatively safe alternative to surgery in patients with high surgical risk.