Problematic bile duct stones: polyvalent treatment.

Background: The availability of different methods for the non-surgical treatment of complicated bile duct stones makes it possible to choose the most appropriate therapy on the basis of the particular characteristics of each individual case and a careful evaluation of their related risks/benefits/costs.

Methods: The present study involved 26 patients treated using different techniques; in some cases, after the failure of the first approach, one of the alternative treatments was adopted. Twenty-one of the patients had isolated stones that were large (> 20 mm in diameter: 11 cases), impacted (5) or upstream of a stenotic tract; five had multiple stones (two of whom had undergone previous biliodigestive anastomosis and two had Caroli's disease). The initial treatment in 24/26 cases was chemical litholysis with a 2:1 v/v association of monooctanoin and methyl tert-butyl ether.

Results: Total dissolution was obtained in nine cases and partial dissolution leading to subsequent elimination (spontaneous or by means of a basket and/or saline washout) in eight. In the seven patients in whom chemolitholysis was unsuccessful, clearance was obtained surgically (6 cases) or by means of extracorporeal shockwave lithotripsy (ESWL). The remaining two patients were successfully treated by means of first-choice ESWL and saline washout.