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Carrilho-Ribeiro L, Pinto-Correia A, Velosa J, Carneiro De Moura M. A ten-year prospective study on gallbladder stone recurrence after successful extracorporeal shock-wave lithotripsy. Scand J Gastroenterol 2006; 41:338-42. [PMID: 16497623 DOI: 10.1080/00365520500483256] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The risk of recurrence has limited the acceptability of conservative therapies of gallbladder stones. The aim of the present study was to determine the long-term rate of stone recurrence and its risk factors after successful extracorporeal shock-wave lithotripsy (ESWL). MATERIAL AND METHODS The study comprised a prospective ultrasound follow-up at yearly intervals or whenever biliary pain was reported. A total of 192 consecutive patients (primary single stones, n=159; primary 2 or 3 stones, n=33) were followed for up to 11.2 years after becoming stone-free and after termination of adjuvant treatment with ursodeoxycholic acid (UDCA). RESULTS Eighty-four patients developed recurrent stones after a median of 2.6 years (maximum?=?8.8 years). The 108 patients without recurrence were followed for a median of 6.7 years (maximum=11.2 years). By actuarial analysis, the cumulative recurrence rates for these 192 stone-free patients were 27%+/-3%, 41%+/-4% and 54%+/-4% (observed +/-SE) at 3, 5 and 10 years, respectively. Cox's regression analysis was used to identify the presence of slight calcification in the primary stone(s) as a protective feature against recurrence (p=0.03). CONCLUSIONS 1) The risk of recurrence continues to increase over time, and although it rises less steeply after 5 years, it does not reach a plateau until at least 10 years. 2) Having had slightly calcified stone(s) seems to be associated with a reduced risk of recurrence and might signal a "burnt out" lithogenic process. 3) The long-term results are unsatisfactory and ESWL of gallbladder stones should be offered only in special cases.
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Barkun AN, Barkun JS, Sampalis JS, Caro J, Fried GM, Meakins JL, Joseph L, Goresky CA. Costs and effectiveness of extracorporeal gallbladder stone shock wave lithotripsy versus laparoscopic cholecystectomy. A randomized clinical trial. McGill Gallstone Treatment Group. Int J Technol Assess Health Care 1998; 13:589-601. [PMID: 9489251 DOI: 10.1017/s0266462300010060] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Thirty-five patients were randomized to extracorporeal shock-wave lithotripsy (ESWL) and 25 to laparoscopic cholecystectomy (LC). Stone disappearance occurred in only 12 of 32 ESWL patients [38% (95% CI: 21-56%)] during a 15-month follow-up. Greater incremental gains in quality of life after 6 months were observed among LC patients (p < .01). Total duration of disability was 6.8 +/- 8.5 days for ESWL, and 22.7 +/- 16.6 days for LC (p < .01). Nine (28%) patients crossed over electively to the LC group, but only 44% of these underwent LC within the next 3 years. ESWL cost Can $58.9/ day of disability saved. ESWL is limited by its selective applicability and modest stone disappearance rate. Its cost-effectiveness is largely dependent on patient acceptance of recurrent episodes of biliary colic due to the persistence of stone fragments.
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Tsuchiya Y, Ishihara F, Kajiyama G, Nakazawa S, Otho M, Tanimura H, Akura Y, Harada M, Hihara M, Kawai Y. Repeated piezoelectric lithotripsy for gallstones with and without ursodeoxycholic acid dissolution: a multicenter study. J Gastroenterol 1995; 30:768-74. [PMID: 8963396 DOI: 10.1007/bf02349645] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The use of bile acid dissolution therapy in extracorporeal shockwave lithotripsy of gallstones, remains controversial. Our study examined whether chemolitholysis after sufficient disintegration enhanced stone clearance within 6 months of the first lithotripsy. A total of 143 patients who developed one to three radiolucent stones measuring < or = 30 mm in diameter were randomly separated into two treatment groups: 47% were given lithotripsy alone, and 53% lithotripsy plus ursodeoxycholic acid (UDCA). Repeated piezoelectric lithotripsy was given, with no limit on the total number of treatment sessions, to pulverize or disintegrate stones into fragments < 3 mm. Stones were disintegrated in 97% of all patients, and the fragments were < or = 2 mm in 50% of these patients. According to an intention-to-treat analysis, 52% in the lithotripsy alone group and 58% in the UDCA group were free of stones 6 months after the first lithotripsy (P = 0.61). Of the patients with fragments < or = 2 mm, 71% in the former and 86% in the latter group were free of stones 6 months after the first lithotripsy, with no significant difference between the groups. Biliary pain occurred in 25% of all patients, including 3 with acute cholecystitis. We concluded that the sufficient disintegration of gallstones achieved with repeated lithotripsy enhanced the early clearance of fragments, regardless of whether chemolitholysis was employed.
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Affiliation(s)
- Y Tsuchiya
- First Department of Medicine, Chiba University School of Medicine, Japan
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Tsuchiya Y, Takanashi H, Haniya K, Nishiarai H, Mikami S, Natsuki Y, Kuniyuki H, Saito H, Saito N, Ohto M. An early gallstone clearance following repeat piezoelectric lithotripsy. J Gastroenterol Hepatol 1994; 9:597-603. [PMID: 7865719 DOI: 10.1111/j.1440-1746.1994.tb01568.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Piezoelectric extracorporeal litotripsy was performed in 128 symptomatic patients with radiolucent gall-bladder stones to assess the significance of disintegration in fragment clearance. Up to 10 repeat lithotripsy sessions were scheduled to achieve a fragment target size of < 3 mm. Fragmentation assessed by the size of the largest fragments after the last session was graded into three classes. I: sludge-like disintegration, 18%; II: < 3 mm (mean +/- s.d., 1.7 +/- 0.5 mm), 56%; and III: > or = 3 mm (3.3 +/- 0.6), 26%. All patients were initially subjected to lithotripsy alone. Bile acid dissolution therapy was started only when ultrasonography failed to show the evidence of decrease in the < 3 mm fragments during a 1 month follow up. Finally, 69 patients (54%) were treated by lithotripsy alone, and the remaining 59 received additional dissolution therapy at a mean period of 2.5 months after the initial lithotripsy. The rate of complete clearance in class I, II and III patients was 91, 42 and 10% at 6 months and 100, 68 and 49% at 18 months, respectively. Significant differences were noted between the three fragmentation grades (I vs II, III, P < 0.0001; II vs III, P < 0.02). The patients with complete clearance within 6 months were seen only in those treated by lithotripsy alone, while the majority (87%) of patients with complete clearance during the later period were seen in those treated by additional dissolution therapy. We conclude that a high degree of fragmentation appears to lead stones to an earlier period clearance, and reduce the need for dissolution therapy.
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Affiliation(s)
- Y Tsuchiya
- First Department of Medicine, Chiba University School of Medicine, Japan
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Bateson MC. Gastroenterology--II: Small and large bowel, pancreas and biliary system. Postgrad Med J 1994; 70:620-4. [PMID: 7971625 PMCID: PMC2397750 DOI: 10.1136/pgmj.70.827.620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- M C Bateson
- General Hospital, Bishop Auckland, Co., Durham, UK
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Soehendra N, Nam VC, Binmoeller KF, Koch H, Bohnacker S, Schreiber HW. Pulverisation of calcified and non-calcified gall bladder stones: extracorporeal shock wave lithotripsy used alone. Gut 1994; 35:417-22. [PMID: 8150358 PMCID: PMC1374602 DOI: 10.1136/gut.35.3.417] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Using a modified electromagnetic lithotripter (Siemens), extracorporeal shock wave lithotripsy (ESWL) was performed in 260 patients with gall bladder stones. Exclusion criteria for treatment were a non-functioning gall bladder, subcostal gall bladder location, and multiple stones occupying more than three quarters of the gall bladder volume. Stone pulverisation was the end point of ESWL. The number of shock wave discharges and sessions was not limited. Pulverisation was achieved in 250 patients (96.1%) after a median of three ESWL sessions (range 1-21). The number of sessions required depended upon stone composition and burden. More than three sessions were required in 60.2% of patients with calcified stones compared with 35.9% of patients with non-calcified stones (p < 0.001). 65.8% of patients with stones measuring more than 30 mm in total diameter required more than three sessions compared with 42.9% of patients with a stone burden less than 30 mm (p < 0.01). At 18-24 (8-12) months follow up, stone clearance was achieved in 94.3% (80.4%) of patients with non-calcified stones, compared with 89.5% (76.8%) in patients with calcified stones and in 75% (71.4%) of patients with a total stone diameter more than 30 mm compared with 95.7% (80.4%) for patients with a total stone diameter less than 30 mm (p < 0.05). ESWL related complications (gross haematuria) occurred in three patients. Thirty six (13.8%) patients experienced biliary colic; four had cholecystectomy, and five endoscopic papillotomy because of common bile duct obstruction. Stone recurrence was seen in 5.3% of patients over a follow up period of up to two years (median 16.6 months).
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Affiliation(s)
- N Soehendra
- Department of Endoscopic Surgery, University Hospital of Hamburg, Germany
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Plaisier PW, van der Hul RL, Terpstra OT, Bruining HA. Current role of extracorporeal shockwave therapy in surgery. Br J Surg 1994; 81:174-81. [PMID: 8156327 DOI: 10.1002/bjs.1800810205] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In urology the introduction of extracorporeal shockwave therapy brought a revolutionary change to the management of urinary calculi. This inspired the introduction of shockwave therapy in several fields of surgery; it has been applied as a potential alternative to several operative procedures but is still experimental. So far, the major application of shockwave therapy has been lithotripsy of stones in the gallbladder, common bile duct, pancreatic duct and salivary gland ducts. Other applications are in the non-operative management of bone healing disturbances and in the inhibition of tumour growth. Steps towards selective thrombus ablation and pretreatment of heavily calcified arteries have also been made. In this review, the applications of extracorporeal shockwave therapy in several areas of surgery are discussed. It is concluded that, for selected patients, shockwave treatment may serve as a useful addition to the surgical armamentarium.
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Affiliation(s)
- P W Plaisier
- Department of Surgery, Erasmus University Hospital, Rotterdam, The Netherlands
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Paumgartner G, Pauletzki J, Sackmann M. Ursodeoxycholic acid treatment of cholesterol gallstone disease. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1994; 204:27-31. [PMID: 7824875 DOI: 10.3109/00365529409103622] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Bile acid dissolution therapy alone or in combination with extracorporeal shock-wave lithotripsy continues to be a safe and effective non-surgical treatment for highly selected patients with cholesterol gallstone disease. Its disadvantages are the duration of drug treatment and potential stone recurrence. Its advantages, however, are non-invasiveness, low rate of morbidity, and lack of mortality. Considering the variety of options in modern gallstone therapy, the careful selection of treatment should be tailored to the individual patient's clinical and personal situation. This will involve the patient in the decision-making process.
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Stölzel U, Koszka C, Gregor M, Ziegler K, Zimmer T, Riecken EO. Lithotripsy of an impacted calcified stone in the cystic duct accompanied by cholecystitis in severe Crohn's disease. Gut 1993; 34:1145-7. [PMID: 8174971 PMCID: PMC1374372 DOI: 10.1136/gut.34.8.1145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A 35 year old women patient with Crohn's disease and previous multiple abdominal operations presented with a calcified stone of 12 mm diameter in the cystic duct giving rise to cholecystitis. The surgeons declined to operate because of extensive intra-abdominal adhesions caused by multiple intestinal resections and chronic enterocutaneous fistulas. It was possible to fragment the stone in three lithotripsy sessions. The fragments were excreted spontaneously through the ductus choledochus and the cholecystitis was cured by antibiotic treatment. The patient remained symptom free after 12 months.
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Affiliation(s)
- U Stölzel
- Department of Gastroenterology, Klinikum Steglitz, Free University of Berlin, Germany
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Affiliation(s)
- D E Johnston
- Department of Medicine, New England Medical Center, Boston, MA 02111
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Sackmann M, Eder H, Spengler U, Pauletzki J, Holl J, Paumgartner G, Sauerbruch T. Gallbladder emptying is an important factor in fragment disappearance after shock wave lithotripsy. J Hepatol 1993; 17:62-6. [PMID: 8445221 DOI: 10.1016/s0168-8278(05)80522-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The role of gallbladder emptying in fragment disappearance following shock wave lithotripsy of gallstones is poorly understood. We studied gallbladder motility in two groups of patients who had been treated by electrohydraulic shock wave lithotripsy and bile acid dissolution therapy. Group I (n = 20) consisted of patients with fragment disappearance within 18 months after lithotripsy, while patients in group II (n = 20) still harboured fragments in the gallbladder 18 months after lithotripsy. Fasting gallbladder volume was 19 +/- 10 ml (mean +/- S.D.) in group I, and 24 +/- 12 ml in group II (not significant). The residual volume was 8 +/- 9 ml in group I, but 18 +/- 14 ml in group II (p < 0.005). Thus, patients in group I ejected nearly twice as much of the fasting gallbladder volume as patients in group II. This difference in gallbladder emptying was still present if only the patients with single stones were compared in both groups. From the results of this retrospective study we conclude that gallbladder emptying is an important factor for complete fragment disappearance after gallstone disintegration by extracorporeally generated shock waves. Further prospective studies are needed to confirm these observations.
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Affiliation(s)
- M Sackmann
- Department of Medicine II, Klinikum Grosshadern, University of Munich, Germany
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Abstract
Within the past 7 years, gallbladder lithotripsy by shockwaves has been proven to be a safe and effective non-invasive therapy for selected patients with gallstone disease. While regulatory decisions prevent shockwave therapy from being used more frequently in the USA, the number of patients treated in Europe and Asia is increasing constantly. At our institution, a relatively constant number of about 250 new patients per year have been treated since 1988 (Figure 4). About 20% of patients with gallstones are suitable for shockwave therapy according to present criteria. The rate of evacuation of all fragments is determined by the initial stone number and stone size, the success at stone fragmentation, adjuvant bile acid dissolution therapy, and gallbladder contractility. In contrast to laparoscopic cholecystectomy (Dubois et al, 1989; Perissat et al, 1989; Southern Surgeons Club, 1991), shockwave therapy does not require general anaesthesia. And in contrast to direct contact dissolution therapy of gallbladder stones using MTBE (Thistle et al, 1989), lithotripsy is non-invasive. In the majority of patients, complete fragment disappearance takes several months. Preliminary analyses of the cost-effectiveness of lithotripsy have revealed that lithotripsy, including retreatments and bile acid medication for recurrent stones, costs about as much as open cholecystectomy (Rothschild et al, 1990; Bass et al, 1991). The ideal patient for gallbladder lithotripsy has a single radiolucent stone < or = 20-25 mm in diameter in a functioning gallbladder (Figure 1). In patients with such stones, nearly all studies have confirmed a favourable outcome with rapid clearance of all fragments and a relatively low rate of stone recurrence. For carefully selected patients, extracorporeal shockwave lithotripsy is therefore an attractive non-invasive therapy.
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Affiliation(s)
- M Sackmann
- Department of Medicine II, Klinikum Grosshadern, University of Munich, Germany
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Paumgartner G. Gallbladder stones: choice of treatment. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1992; 6:679-88. [PMID: 1486208 DOI: 10.1016/0950-3528(92)90046-h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- G Paumgartner
- Department of Medicine II, Klinikum Grosshadern, University of Munich, Germany
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