Extracorporeal shock-wave lithotripsy for gallstone ileus

Abstract

Meyenberger et al.1Meyenberger C Michel C Metzger U Koelz H-R. Gallstone ileus treated by extracorporeal shock-wave lithotripsy.Gastrointest Endosc. 1996; 43: 508-511Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar reported a case involving a gallstone obstructing the colon that was successfully treated by extracorporeal shock-wave lithotripsy (ESWL). We performed ESWL in three patients with gallstone ileus but did not achieve stone fragmentation in any of them. Gallstones were obstructing the bulb (Bouveret's syndrome) in two cases and the ileum in one case. The three patients had severe occlusive symptoms. Patients were treated in the prone position using the electromagnetic Lithostar lithotriptor (Siemens, Erlangen, Germany) as previously described.2Delhaye M Vandermeeren A Baize M Cremer M. Extracorporeal shock-wave lithotripsy of pancreatic calculi.Gastroenterology. 1992; 102: 610-620Abstract PubMed Google Scholar Stones were easily targeted with the double x-ray focusing system because they were huge (40 to 70 mm in diameter) and calcified. In each case, a total of 5000 to 6000 discharges were delivered with a power of 0.28 to 0.54 mJ/mm2Delhaye M Vandermeeren A Baize M Cremer M. Extracorporeal shock-wave lithotripsy of pancreatic calculi.Gastroenterology. 1992; 102: 610-620Abstract PubMed Google Scholar during a single session. The failure of stone fragmentation was confirmed by surgery in the case of ileal obstruction and by upper gastrointestinal endoscopy for the two stones located in the bulb. The latter were fragmented endoscopically using laser (Lithognost, Olympus, Tokyo, Japan) and electrohydraulic lithotripsy (Lithotron EL-21, Waltz Elektronik Gmbh, Rohrdorf, Germany) after failed mechanical lithotripsy using the BML-2Q basket catheter (Olympus). Fragments of significant size were removed orally, except one of 20 × 35 mm, which was left in the stomach. It obstructed the ileum 2 weeks later and the 84-year old patient died of bronchopneumonia 3 weeks after surgical enterolithotomy. The two other patients (one of them after surgery) had an uneventful course. We think that the failure of ESWL to fragment stones in our cases was mainly related to intestinal gas. Stones were easily targeted and numbers as well as powers of discharges were similar to those reported in other cases of gallstone ileus successfully treated by ESWL.1Meyenberger C Michel C Metzger U Koelz H-R. Gallstone ileus treated by extracorporeal shock-wave lithotripsy.Gastrointest Endosc. 1996; 43: 508-511Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Sackmann M Holl J Haerlin M et al.Gallstone ileus successfully treated by shock-wave lithotripsy.Dig Dis Sci. 1991; 36: 1794-1795Crossref PubMed Scopus (31) Google Scholar, 4Holl J Sackmann M Hoffmann R Schödussler P Sauerbruch T Jüngst D Paumgartner G Shock-wave therapy of gastric outlet syndrome caused by a gallstone.Gastroenterology. 1989; 97: 472-474PubMed Google Scholar Gas-containing bowel loops are most often interposed between gallstones in the digestive tract and the abdominal wall, rendering stone visualization by ultrasound difficult.5Lasson A Lorén I Nilsson A Nirhov N Nilsson P Ultrasonography in gallstone ileus: a diagnostic challenge.Eur J Surg. 1995; 161: 259-263PubMed Google Scholar These gases attenuate or reflect shock-waves.3Sackmann M Holl J Haerlin M et al.Gallstone ileus successfully treated by shock-wave lithotripsy.Dig Dis Sci. 1991; 36: 1794-1795Crossref PubMed Scopus (31) Google Scholar In our patients, we did not verify if gallstones were demonstrable by ultrasonography, a feature present in all cases of successful treatment by ESWL reported to date.1Meyenberger C Michel C Metzger U Koelz H-R. Gallstone ileus treated by extracorporeal shock-wave lithotripsy.Gastrointest Endosc. 1996; 43: 508-511Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 3Sackmann M Holl J Haerlin M et al.Gallstone ileus successfully treated by shock-wave lithotripsy.Dig Dis Sci. 1991; 36: 1794-1795Crossref PubMed Scopus (31) Google Scholar, 4Holl J Sackmann M Hoffmann R Schödussler P Sauerbruch T Jüngst D Paumgartner G Shock-wave therapy of gastric outlet syndrome caused by a gallstone.Gastroenterology. 1989; 97: 472-474PubMed Google Scholar It seems unlikely that the types of shock-wave generators used (electromagnetic in our cases, electrohydraulic in the others) could have accounted for the differences in fragmentation success inasmuch as both systems have been shown to be equally efficient.6Schneider HT Fromm M Ott R et al.In vitro fragmentation of gallstones: comparison of electrohydraulic, electromagnetic and piezoelectric shockwave lithotripters.Hepatology. 1991; 14: 301-305Crossref PubMed Scopus (12) Google Scholar We propose that gallstones in the duodenum be approached endoscopically. Compared with ESWL, endoscopic lithotripsy techniques are more widely available and are not hampered by gastrointestinal gas. They allow immediate stone fragment removal, which should be as complete as possible to decrease the risk of recurrent gallstone ileus (exemplified in one of our cases). These techniques could also prove to be useful for gallstones in the colon, whereas ESWL remains the only alternative to surgery for gallstones in the small intestine.