Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Extracorporeal shock-wave lithotripsy prior to laparoscopic cholecystectomy. Does it make sense?

The extraction of large gallstones in laparoscopic cholecystectomy either requires the enlargement of one of the incisions or intraoperative lithotripsy. Preoperative extracorporeal shock-wave lithotripsy (ESWL) might theoretically solve the problem and facilitate the extraction of the gallbladder. Ten patients with at least one gallstone larger than 20 mm in diameter underwent ESWL treatment within 24 h prior to laparoscopic surgery. Complete pulverization of stones was achieved in one patient. Fragmentation into pieces smaller than 10 mm could be observed in another three cases. Additional mechanical fragmentation employing forceps was necessary in seven and an enlargement of the incision in five of the 10 patients. Compared to a matched group of 10 control patients with gallstones of corresponding size receiving mechanical lithotripsy, the ESWL did not show an advantage, but rather an increase in costs. It therefore cannot be recommended.

Gallbladder emptying determines early gallstone clearance after shock-wave lithotripsy

BACKGROUND/AIMS

Disappearance of gallbladder stones after shock-wave lithotripsy combined with bile acid therapy depends on mechanical evacuation and dissolution of fragments. Many patients with gallstones have impaired gallbladder emptying and may show delayed stone clearance after lithotripsy.

METHODS

The effect of gallbladder emptying on gallstone clearance after lithotripsy was prospectively studied in 57 patients with one radiolucent gallbladder stone < or = 20 mm. Gallbladder emptying was assessed sonographically before and after 2 weeks of ursodeoxycholic acid (UDCA) treatment.

RESULTS

UDCA increased gallbladder fasting and residual volume and decreased ejection rate but did not affect ejection fraction. Patients with an ejection fraction > 60% achieved complete gallstone clearance after lithotripsy in a higher percentage than patients with smaller ejection fractions (1 month, 31% vs. 7%, P = 0.022; 2 months, 55% vs. 18%, P = 0.003; 3 months, 66% vs. 29%, P = 0.005). Patients who became stone-free within 1 month showed larger ejection fractions than patients with retained fragments (67% +/- 4% vs. 56% +/- 3% before UDCA, P = 0.032; 65% +/- 4% vs. 53% +/- 3% with UDCA, P = 0.017). Further, ejection rate during UDCA therapy was larger in patients with complete gallstone disappearance within 1 month than in patients with delayed fragment clearance (1.57%/min +/- 0.36%/min vs. 0.76%/min +/- 0.09%/min; P = 0.002).

CONCLUSIONS

Gallbladder emptying is a major determinant of early gallstone clearance after lithotripsy.

Combination of extracorporeal shock-wave lithotripsy and dissolution of gallbladder stones with methyl tert-butyl ether: a randomized study

We conducted a prospective randomized study in gallstone patients to determine whether a combination of extracorporeal shock-wave lithotripsy and subsequent dissolution with methyl tert-butyl ether increases the success rate of methyl tert-butyl ether dissolution and shortens treatment time compared with monotherapy with methyl tert-butyl ether. Fifty patients were randomized into two groups. Twenty-five patients underwent extracorporeal shock-wave lithotripsy before contact dissolution with methyl tert-butyl ether, and 25 patients were treated with methyl tert-butyl ether alone. All patients had at least three stones or stones larger than 30 mm that were radiolucent on x-ray and had densities of less than 140 Hounsfield Units (HU) on computed tomography. Overall, the combined approach neither shortened the treatment time significantly vs. monotherapy with methyl tert-butyl ether nor reduced the time of hospitalization. The success rate was slightly but not significantly increased compared with that of methyl tert-butyl ether therapy alone. The recurrence rate was similar in the two groups after a median follow-up of 1 yr. However, when subgroups of patients with at least one stone larger than 15 mm or with stones with densities of more than 60 HU were analyzed, the clearance rate after 5 mo was significantly higher (p < 0.005 and p < 0.025, respectively) in patients subjected to a combination of extracorporeal shock-wave lithotripsy and methyl tert-butyl ether dissolution. Extracorporeal shock-wave lithotripsy and methyl tert-butyl ether did not expose patients to more adverse effects than did treatment with methyl tert-butyl ether alone.

[Laparoscopic cholecystectomy of large gallbladder calculi]

Laparoscopic cholecystectomy is more laborious in patients with large gallbladder stones in that they can only be removed safely after an enlargement of one incision or intraoperative lithotripsy. Preoperative extracorporeal shock-wave lithotripsy (ESWL) might theoretically solve this problem and facilitate the extraction of the gallbladder. Ten patients with minimum one stone > 20 mm of diameter received ESWL treatment within 24 h before operation. Complete pulverization of stones was achieved in only one patient. Additional mechanical fragmentation by forceps was necessary in 7 and an enlargement of the incision in 5 of 10 patients. Compared to 10 patients with corresponding stones and mechanical lithotripsy ESWL showed no advantage and cannot be recommended because of increase of costs.

[Shockwave therapy of gallstones]

Extracorporeal shock-wave lithotripsy (ESWL) is a helpful adjunct for those bile duct stones which cannot be extracted by routine endoscopic measures including mechanical lithotripsy. For very large or impacted stones in the bile duct or stones in the intrahepatic biliary tree, and also for stones located in proximity to a bile duct stenosis, shock-wave therapy has proven to be safe and successful. More than 85% of the patients become free of stones after this therapy; they otherwise would have had to undergo high-risk open bile duct surgery. For gallbladder calculi, the pivotal factor for complete fragment disappearance after shock-wave therapy is sufficient stone disintegration. Only if fragments not larger than 3 mm are achieved, complete expulsion and/or dissolution of these fragments may be expected in a high percentage of the patients. Optimal candidates include patients with a single, radiolucent stone in a well-contracting gallbladder. For this group, ESWL is a safe and effective noninvasive therapeutic alternative.

[Pathophysiology of cholesterol gallstones]

Cholelithiasis is a civilization-related disease with multifactorial causation. The supersaturation of the bile with cholesterol is a deciding risk factor, which, however, does not lead to gallstone formation in each individual case. The connection between supersaturated bile and the formation of stone whose primary constituent is cholesterol, are the cholesterol-monohydrate crystals. Several risk factors lead to cholesterol supersaturation of the bile. Other risk factors induce or maintain the nucleation of the cholesterol crystals. In the following paper the nucleating and inhibiting factors and the pathophysiology of cholesterol gallstones will be discussed.

[Lithogenicity and bile acid pattern in choleretic administration (3-n-butoxy-1-phenoxy-propanol: febuprol) in patients with functional right upper quadrant pain]

10 patients with right upper quadrant pain were treated with a choleretic agent (Febuprol; 3 X 200 mg t. i. d.) and placebo in a cross-over double dummy technique for 16 weeks. Lithogenic index, bile acid profile and serum lipids were determined every 4 weeks. During Febuprol application the clinical symptoms were relieved (0.87 +/- 1.3 vs. 1.39 +/- 0.21 (placebo); p less than 0.05, semiquantitative score). Biliary lithogenicity (1.45 +/- 0.6 vs. 1.09 +/- 0.12; n. s.), bile acid profile and serum lipids showed no statistically significant change, although serum cholesterol levels seemed to fall during Febuprol application.

Rapid and accurate reversed-phase high-performance liquid chromatographic determination of conjugated bile acids in human bile for routine clinical applications. Therapeutic control during gallstone dissolution therapy

This paper introduces a new method to detect the taurine and glycine conjugates of five different bile acids (cholic acid, deoxycholic acid, chenodeoxycholic acid, ursodeoxycholic acid and lithocholic acid) in human bile. Advantages of this method are sufficient separation of compounds within a short period of time and a high rate of reproducibility. Using a mobile phase gradient of acetonitrile and water, modified with tetrabutylammonium hydrogen sulphate (0.0075 mol/l), we were able to maximize the differentiation between ursodeoxycholic acid and lithocholic acid, which is of primary interest during conservative gallstone dissolution therapy. Use of this gradient reduced analysis time to less than 0.5 h. Recovery rates for this modified method ranged from 94% to 100%, and reproducibility was 98%, sufficient for routine clinical applications.

[Dissolution of recurrent stones in the choledochus by a modified irrigation treatment via an indwelling nasobiliary catheter]

Alternating fluid rinsing with a modified glyceromono-octanoate (GMOC) and bile salt-EDTA (BA-EDTA) solution via an endoscopically placed indwelling nasal biliary catheter was performed on 15 patients (13 women, 2 men) with recurrent stones in the choledochal duct after cholecystectomy. Of 12 radiotranslucent and three radioopaque concrements with a mean diameter of 1.72 X 2.05 cm (largest concrement: 3.0 X 3.5, smallest 1.0 X 2.1 cm) 13 were dissolved (87% success rate). In one patient chemolitholysis had to be stopped because of electrolyte abnormalities, before treatment had been completed. After the end of treatment all patients were free of symptoms and during a fairly long follow-up period no stone recurrences were observed.