Biliary stenting in the management of bile duct stones.

Role of biliary stenting in the management of bile duct stones in the elderly Nearly a third of patients with common bile duct stones are at risk of developing recurrent cholangitis or pancreati-tis.' These complications carry a significant mortality in elderly, infirm patients so that prompt intervention to clear the duct of stones (or at least establish an uninterrupted flow of bile) is, particularly important. Endoscopic sphincterotomy and basket extraction is the initial treatment of choice for a patient of any age with choledocholithiasis, which clears the bile duct of stones in up to 90%.2-4 Elderly patients in whom sphincterotomy and basket extraction is unsuccessful present a challenging clinical problem, as surgical exploration carries an unacceptably high mortality.56 Many alternative therapeutic approaches in those few patients in whom sphincterotomy and basket extraction is unsuccessful, include:-surgical exploration, mechanical lithotripsy, extracorporeal shock wave litho-tripsy (ESWL), contact dissolution, electrohydraulic and laser lithotripsy, and stenting. Surgical exploration Surgical exploration of the common bile duct is well tolerated by young, fit patients where the death rate is about 1% or less.7-9 In elderly and infirm patients the death rate may be as high as 10% or more,7 10 which makes surgery an unattractive proposition, particularly in patients with significant concomitant cardiorespiratory disease. Mechanical lithotripsy Using a conventional Dornier basket, successful endo-scopic extraction of common bile duct stones is unpredictable for stones greater than 15 mm diameter and mechanical lithotripsy offers an alternative approach."1 This is performed using an endoscopically placed crushing basket. Several different designs are now available. The success rate using this technique can be as high as 80-90%12-15 although several attempts are often required. The successful application of this technique seems to be inversely proportional to stone size as it is difficult to entrap very large stones within the basket. The success rate may be as low as 25% in stones with a diameter exceeding 25 cm."1 Stones situated above a stricture also present difficulties. Extracorporeal shock wave lithotripsy (ESWL) ESWL fragments large stones using high pressure waves generated by spark gap, piezoelectric laser of electromagnetic generation. This method of treatment clears retained bile duct stones in 60-90% of patients, although some patients require repeated treatments. 16-21 Mortality associated with ESWL ranges from 0-2%. Major adverse effects are uncommon even in the elderly.16-21 Cost is the major drawback with ESWL, particularly as there are several cheap and equally effective non-surgical alternatives. Furthermore, capital …