Résumé
Le traitement des calculs de la voie biliaire principale (VBP) est endoscopique dans un grand nombre de cas. La sphinctérotomie suivie d’une extraction du ou des calculs est en règle générale suffisante. Il existe cependant des situations d’échecs, qui vont nécessiter d’utiliser d’autres techniques pour éviter la chirurgie. Il importe de connaître les critères prédictifs d’échec. Ceux-ci sont principalement la taille du calcul, leur nombre, l’impaction dans le sphincter, et le diamètre de la VBP inférieur à celui du calcul. Dans de telles situations, la première technique consiste à réaliser une lithotritie mécanique (LM) qui permet l’extraction des calculs difficiles dans plus de 90 % des cas. En cas d’échec, d’autres alternatives sont possibles. La plus simple consiste à mettre une ou plusieurs prothèses plastiques, qui, lorsqu’elles sont laissées en place, entraînent souvent une fragmentation des calculs, voire leur élimination. La deuxième technique, plus récente, est la macrodilatation du sphincter d’Oddi. Celle-ci est effectuée avec un ballon dont le diamètre est adapté à celui du calcul (12 à 20 mm). Enfin, une lithotritie intracorporelle (électrohydraulique ou laser) peut être réalisée, en centre expert le plus souvent.
Abstract
The management of large biliary stones often requires endoscopic therapy. It includes sphincterotomy followed by stone extraction, which generally leads to a complete bile duct clearance. However, these techniques may fail because of stone size and number, stone impaction, and a tapered lower bile duct. In such situations, a mechanical lithotripsy has to be performed which enables a stone fragmentation and an extraction in more than 90%. When lithotripsy fails, stent insertion allows stone fragmentation which facilitates their extraction at a second ERCP. Endoscopic papillary large balloon dilation has to be performed at a diameter related to the stone diameter (usually 12 to 20 mm) with excellent results and few complications. At last, intraductal lithotripsy (electrohydraulic or laser), are efficient but require experienced centers.
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Grandval, P., Laquière, A., Bernardini, D. et al. Traitement endoscopique des gros calculs de la voie biliaire principale non opérée. Acta Endosc 42, 13–20 (2012). https://doi.org/10.1007/s10190-012-0230-4
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DOI: https://doi.org/10.1007/s10190-012-0230-4
Mots clés
- Cholangiopancréatographie rétrograde endoscopique (CPRE)
- Lithiase de la voie biliaire principale
- Lithotritie
- Macrodilatation du sphincter d’Oddi