Extracorporeal Shock Wave Lithotripsy Sessions Research Articles

The effect of intracalyceal distribution on the clearance of renal stones of > or = 20 mm in children after extracorporeal lithotripsy.

To determine the effect of the intracalyceal distribution of renal stones on clearance rates after treating paediatric nephrolithiasis with extracorporeal shock wave lithotripsy (ESWL). We assessed a retrospective case series of children (aged < or = 14 years) undergoing lithotripsy on an MPL 9000 (Dornier GmbH, Germany) echo-guided lithotripter. Patients were identified using an international coding and indexing system and ESWL registry. In all, 125 children were treated during 1990-2003, but 21 had stones of > or = 20 mm. Stone clearance was assessed at 1 and 3 months, the stone-free state being defined as no radiological evidence of stone or fragments of < or = 3 mm. Failed treatments were analysed to identify any correlation with stone site. The overall stone-free rate was 81%; in four children the treatment failed (all girls) and subsequently they required ancillary procedures. Nineteen patients (90%) received up to three sessions of ESWL; two required four or more sessions. Of the four children in whom treatment failed, two had JJ stents; the stones were in the lower pole calyx in two, and the renal pelvis and lower pole calyx in two. The mean stone size in those where treatment failed was 25 mm, vs 21 mm in the stone-free group. The complication rate was 19%, but only one child required admission to hospital. ESWL is very effective for renal stones in children, with minimal morbidity. Lower pole and partial staghorn stones with a major component in the lower pole calyx should preferably be treated by a percutaneous approach.

Outcome and Safety of Extracorporeal Shock Wave Lithotripsy as First-Line Therapy of Lower Pole Nephrolithiasis

Introduction: The aim of this study is to assess the efficiency of extracorporeal shock wave lithotripsy (ESWL) as initial therapy for isolated lower pole kidney stones smaller than 20 mm. Patients and Methods: During a 24-month period 116 patients with previously untreated single stones under 20 mm in diameter were treated with a Dornier lithotripter S. They were analyzed with regard to stone site and size, number of ESWL sessions, auxiliary measures, retreatment rates, complications and the time taken for stone clearance. Results: 76 patients (65.5%) became stone free, 50 of them (43.1%) within 3 months after ESWL. Depending on stone size the stone-free rates were 67.1% for patients with a stone diameter of <10 mm (59 of 88 patients), and 60.7% for stone diameters between 10 and 20 mm (17 of 28 patients). Complications during and after treatment were rare, i.e. the necessity of ureteral stent insertion due to colic (n = 10), endoscopic stone removal (n = 2), acute pyelonephritis (n = 1), stonestreet (n = 1) and 1 case of hematoma not requiring intervention. The recurrence rate during follow-up (13.2–36.9, mean 25.0 months) was low: 16 patients (13.8%) had recurrent or persistent stones, and 74 patients (63.8%) had no evidence of urolithiasis. Conclusions: ESWL is a safe and efficient first-line therapy for treatment of isolated small lower pole kidney stones with acceptable stone-free rates, low morbidity, few complications and a low stone recurrence rate.

Pediatric Staghorn Calculi: The Role of Extracorporeal Shock Wave Lithotripsy Monotherapy With Special Reference to Ureteral Stenting

Pediatric Staghorn Calculi: The Role of Extracorporeal Shock Wave Lithotripsy Monotherapy With Special Reference to Ureteral Stenting

Music decreases anxiety and provides sedation in extracorporeal shock wave lithotripsy

Objectives To evaluate the efficacy of music on sedation in extracorporeal shock wave lithotripsy (ESWL) treatment to compare its anxiolytic effects with those of midazolam. Methods Ninety-eight urolithiasis patients were randomly divided into two groups. Hemodynamic parameters, including mean arterial pressure, heart rate, respiration rate, and oxygen saturation, were recorded in all patients. In 50 patients (group 1), 2 mg of midazolam was administered intravenously 5 minutes before ESWL. In group 2 (n = 48), music chosen by the patients was listened to with a headset and continued during the treatment. The visual analog scale (0 to 100 mm), Observer’s Assessment of Alertness/Sedation Scale, State and Trait Anxiety Inventory-Trait Anxiety test, and State and Trait Anxiety Inventory-State Anxiety test were administered for the evaluation of pain, sedation level, and patient anxiety. Results For the hemodynamic parameters, a statistically significant decrease in mean arterial pressure was noted at the end of the ESWL procedure in group 2 and in oxygen saturation from the 10th minute to the end of the treatment in group 1. Although the visual analog scale, Observer’s Assessment of Alertness/Sedation Scale, and State and Trait Anxiety Inventory-State Anxiety test did not show statistically significant differences, the State and Trait Anxiety Inventory-Trait Anxiety score was found to be lower in the music group (group 2) than in the midazolam group (group 1). Conclusions With the anxiolytic effects of music, ESWL can be performed more effectively with the patient in a comfortable state. Listening to music by patients during the ESWL session is a feasible and convenient alternative to sedatives and anxiolytics.

Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy - the controversy continues.

BackgroundTo determine factors influencing the clearance of fragments after extra-corporeal shock wave lithotripsy (ESWL) for lower pole calyceal (LPC) stones.MethodsIn the period between July 1998 and Oct 2001, 100 patients with isolated lower polar calyceal calculi ≤ 20 mm, in patients aged ≥ 14 years, were included in the study. Intravenous urograms (IVU) were reviewed to define the LPC anatomy (width of the infundibulum and pelvicalyceal angle). Study end points i.e. stone free status; number of shock waves used and number of sessions were correlated with variables like LPC anatomy, body mass index and stone size.ResultsAt three months follow up the clearance for stone size ≤ 10 mm, 11–15 mm and 16–20 mm were 95, 96 and 90% respectively. Patients with acute LPC (<90°) and obtuse angle (>90°) had stone clearance of 94 and 100% respectively. For the infundibular width of < 4 mm, the stone clearance was 93% were as for > 4 mm, it was 100%. For body mass index (BMI) less than and > 30 kg/m2, the stone clearance was 92 and 95% respectively.ConclusionsThere is a trend towards more ESWL sessions and shock wave requirement in patients with acute pelvi-calyceal angle and narrow infundibulum but it is not statistically significant. Size (≤ 20 mm) and BMI has no relation with stone clearance. With modern lithotripter, stones up to 20 mm could primarily be treated by ESWL, irrespective of an un-favorable lower polar calyceal anatomy and body habitus.

Does size and site matter for renal stones up to 30-mm in size in children treated by extracorporeal lithotripsy?

Objectives To determine the safety and efficacy of extracorporeal shock wave lithotripsy (ESWL) in the treatment of pediatric nephrolithiasis and to analyze the impact of renal stone size and location on stone clearance. Methods This was a retrospective case series of pediatric patients (14 years or younger) undergoing lithotripsy using a Dornier MPL 9000 echo-guided lithotriptor. Patients were identified using an international coding and indexing system (9th edition) and ESWL registry. One hundred five patients were treated from January 1990 to December 2001. Stone clearance was assessed at 1 and 3 months. A stone-free state was defined as no radiologic evidence of stone or fragments 3 mm or less. Treatment failure was analyzed to find any correlation with stone size and site. Results The overall stone-free rate was 95%. The treatment failed in 5 patients, who subsequently required ancillary procedures. Three patients received one session of ESWL, after which they were lost to treatment and were not analyzed further. Four of the five patients with treatment failure had a double- J stent; the stones were located in the lower pole calix in 2, renal pelvis and lower pole calix in 1, and at the ureteropelvic junction in 2 patients. The mean stone size in the treatment failure group was 15.88 mm compared with 14 mm in the stone-free group. The complication rate was 8%, but only 3 patients required admission. Conclusions ESWL is highly effective for pediatric renal stones, with minimal morbidity. Stone clearance is not adversely affected by a stone size up to 30 mm; however, lower pole caliceal stones and stones impacted at the ureteropelvic junction have relatively poorer clearance. Eighty percent of patients who failed to clear their stones had a double-J stent.

Clinical outcomes in patients who undergo extracorporeal shock wave lithotripsy for chronic calcific pancreatitis

Background: There is controversy as to whether extracorporeal shock wave lithotripsy fragmentation and ERCP retrieval of pancreatic stones are associated with relief of chronic pain or relapsing attacks of pancreatitis. Our most recent experience with this technology is reviewed. Methods: Forty patients with chronic calcific pancreatitis who required extracorporeal shock wave lithotripsy between 1995 and 2000 to facilitate pancreatic duct stone removal were retrospectively reviewed. Data collected included patient presentation, number of lithotripsy and ERCP sessions required, complications, and outcomes measures to include pre- and post-ESWL pain scale, monthly oxycodone (5 mg)-equivalent pills ingested, yearly hospitalizations, and need for subsequent surgery. Results: A single extracorporeal shock wave lithotripsy session was required for 35 patients who underwent a total of 86 ERCPs to achieve complete stone extraction from the main pancreatic duct. Minor complications occurred in 20%. There was one episode of pancreatic sepsis that was treated with antibiotics and removal of an occluded pancreatic prosthesis. At a mean [SD] follow-up of 2.4 (0.6) years, 80% of patients had avoided surgery and there was a statistically significant decrease in pain scores (6.9 [1.3] vs. 2.9 [1.1]; p = 0.001), yearly hospitalizations for pancreatitis (3.9 [1.9] vs. 0.9 [0.9]; p = 0.001), and oxycodone-equivalent narcotic medication ingested monthly (125 [83] vs. 81 [80]; p = 0.03). Conclusions: Extracorporeal shock wave lithotripsy fragmentation of pancreatic duct calculi in conjunction with endoscopic clearance of the main pancreatic duct is associated with significant improvement in clinical outcomes in most patients with chronic pancreatitis. (Gastrointest Endosc 2002;56:496-500.)

Evaluation Of Disintegration In Prevesical Ureteral Calculi By 3-Dimensional Endo-Ultrasound With Surface Rendering

Lower ureteral calculi are accessible by transrectal endo-ultrasound, including 3-dimensional image processing with surface rendering. We analyzed the efficiency of this innovative technology compared with that of standard radiographic examinations with respect to the outcome of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Marietta, Georgia). In patients with prevesical or intramural calculi we performed excretory urography and transrectal endo-ultrasound using a Combison 530 device (Kretz Technik, Zipf, Austria) with integrated optional 3-dimensional image processing and surface rendering. A total of 102 ESWL cases (108 radiopaque stones, 145 ESWL sessions) were included in the study. One day after ESWL an evaluation was independently performed by a radiologist (plain x-ray) and a urologist (transrectal endo-ultrasound). Results were compared to the outcome determined during further followup. All stones were evaluable by endo-ultrasound with surface rendering, whereas in 27 cases the stone was hidden by extraureteral processes on followup radiography. Immediately after endo-ultrasound 8 calculi were passed. In 7 of the remaining 110 cases (6.4%) radiographic examination did not confirm sonographic findings. In these cases evaluation by surface rendering proved to be correct on followup. Endo-ultrasound with surface rendering proved to be highly effective for evaluating ESWL success in cases of prevesical ureteral stones. This technique is independent from bowel gas or other factors that impede radiological imaging. It is safe, easy to learn, well tolerated by patients and does not expose them to radiation.

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal Shock Wave Lithotripsy in Children

Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones

The aim of this study was to determine the safety and effectiveness of extracorporeal shock wave lithotripsy (ESWL) in difficult bile duct stones resistant to endoscopic extraction. From January 1997 to February 2002, combined treatment with endoscopy and ESWL was used in 19 patients who had undergone unsuccessful endoscopic bile duct stone extraction after sphincterotomy. The procedure was carried out using analgesic and sedative drugs or deep sedation, prophylactic antibiotic therapy, and monitoring of vital signs. Bile duct stone localization was performed by contrast injection through nasobiliary drainage and fluoroscopy. After each ESWL session, lavage was performed through drainage and stone fragments were extracted endoscopically. The 19 patients presented high surgical risk due to advanced aged and/or concomitant diseases. All presented jaundice and pain and nine (47.3%) presented associated cholangitis. Thirty ESWL sessions were performed (1.57 sessions per patient), with a mean of 2,120 shock waves per session. In 16 of the 19 patients (84.2%), combined treatment with ESWL and subsequent instrumental endoscopic extraction achieved complete clearance of the biliary tract. The treatment failed in 3 patients who were referred for surgical treatment. No early or late complications were observed, except in one patient who presented a self-limiting febrile syndrome. Therapeutic endoscopy combined with ESWL is safe and effective in patients with difficult bile duct stones. It represents a therapeutic alternative in patients at high surgical risk.

IS THE PEDIATRIC URETER AS EFFICIENT AS THE ADULT URETER IN TRANSPORTING FRAGMENTS FOLLOWING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR RENAL CALCULI LARGER THAN 10 MM.?

We determined whether the thin ureter of the young child transports stone fragments after extracorporeal shockwave lithotripsy (ESWL) as efficiently as the adult ureter does. This determination was done by comparing the outcome after lithotripsy of renal stones greater than 10 mm. between young children and adults. Our study group consisted of 38 children 6 months to 6 years old (median 3 years) with renal stones greater than 10 mm. in diameter. This group was further divided into 3 subgroups according to the longest stone diameter on plain abdominal film. There were 21 children with a renal stone diameter of 10 to 15 mm. (subgroup 1), 8, 16 to 20 mm. (subgroup 2) and 9 greater than 20 mm. (subgroup 3). The control group consisted of 38 adults older than 20 years randomly selected from the local ESWL registry. Each adult was matched with a child regarding stone diameter and localization. The control group was similarly divided into subgroups 1a, 2a and 3a. ESWL was performed with the unmodified Dornier HM-3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia). The stone-free rate, complication rate, and need for tubes, including stent or nephrostomy, and greater than 1 ESWL session were compared. The stone-free rate was 95% in the study and 78.9% in the control group (p = 0.086). Stone-free rates were 95%, 100% and 89% in subgroups 1, 2 and 3, and 95%, 65% and 56% in subgroups 1a, 2a and 3a, respectively. There were 10 children and 4 adults who underwent greater than 1 ESWL session (p = 0.14). Then there were 10 children and 6 adults who required a tube before ESWL (p = 0.04), and almost all of them were included in subgroups 3 and 3a. Early complications were rare in both the study and control groups. Late complications had included 2 cases of Steinstrasse in the control and none in the study group. The stone-free rate after ESWL for large renal stones is higher in young children compared to adults with matching stone size. Renal stones greater than 20 mm. often require more than 1 ESWL session. The pediatric ureter is at least as efficient as the adult for transporting stone fragments after ESWL.

Impact of power index, hydroureteronephrosis, stone size, and composition on the efficacy of in situ boosted ESWL for primary proximal ureteral calculi

Objectives. The efficacy, safety, feasibility, and outcome of in situ treatment applied to select proximal ureteral calculi was assessed and analyzed with a view to avoiding auxiliary interventions and providing high clearance rates in the shortest possible time. We studied the impact of several clinically important variables, including power index, degree of hydroureteronephrosis (HDUN), stone size, and composition on the efficacy of sequential in situ boosted extracorporeal shock wave lithotripsy (ESWL) in a select group. The power index requirement for the in situ boosted protocol and the impact of the stone size/composition, degree of HDUN, and clearance rates were also analyzed. Methods. An in situ (no instrumentation) boosted protocol was applied to 130 primary unimpacted proximal ureteral calculi with no prior intervention. A typical session with the Siemens Lithostar Plus comprised 3000 shock waves, in installments of 500, deployed at a power setting of 1 to 4 kV with a gradual stepwise escalation. Sequential boosted additional sessions of ESWL were administered on days 2, 7, and 14, tailored to the degree of fragmentation, clearance status, and amount of residual stone bulk. Several parameters (shock waves, kilovolts used, fluoroscopy time, number of sessions, stone size, composition, fragmentation, clearance, and HDUN) were recorded and the results analyzed statistically. Results. The results were excellent in 83.8%, with a mean duration to complete clearance of 11.3 days. In situ ESWL failed in 7.69%, and the auxiliary intervention rate was 10.7%. Pre-ESWL HDUN was present in 78.3%, the mean power index was 184.6/session/case, and the average stone burden was 8.9 mm 2. Calcium oxalate monohydrate was the most common stone (56%). Renal colic was the most common side effect observed. The power index, fragmentation at the first session, and stone size were found to be the most favorable significant variables affecting stone clearance. The degree of HDUN, number of sessions, and stone composition did not significantly impact the clearance rates. Conclusions. In situ boosted ESWL should be the first-line therapeutic modality in select unimpacted primary proximal ureteral stones.

Urolithiasis in the low birth weight infant: the role and efficacy of extracorporeal shock wave lithotripsy.

Nephrolithiasis in preterm infants rarely requires surgical management. When it persists despite conservative therapy, treatment options are not clearly defined. We report a single institutional experience with extracorporeal shock wave lithotripsy (ESWL)* for the treatment of these small infants. We treated 8 infants (mean age 13 months) with a history of prematurity and 9 persistent stones with a Dornier HM3 lithotriptor between 1996 and 1999. Mean weight was 7,700 gm. Of the infants 7 had been treated with furosemide for bronchopulmonary dysplasia and 1 presented with multiple anatomical abnormalities. Gantry modification with a wooden platform and polystyrene foam positioning was used for lung and visceral protection. Ureteral stents were placed in 5 patients before ESWL. Renal ultrasonography was performed before, and 2 and a mean of 8 weeks after ESWL. Stone risk factors in our population were investigated through a multispecialty approach. Average stone burden was 47.9 mm.2. A total of 9 sessions of ESWL were required for complete fragmentation of the 9 renal stones. A mean total of 2,100 shocks at a mean 16.1 kV. were administered. One patient with bilateral stones was treated in 2 separate sessions after a 4-week interval. No repeat ESWL sessions or other surgical interventions were required in any patient. Renal ultrasonography demonstrated no post-ESWL morphological changes. Practices leading to a higher incidence of neonatal nephrolithiasis at our institution were also identified. ESWL is effective treatment for nephrolithiasis in small infants. Short-term safety has been established but continued long-term functional followup is essential. Multifactorial etiologies of nephrolithiasis must be identified and modified promptly in the care of preterm infants.

UROLITHIASIS IN THE LOW BIRTH WEIGHT INFANT: THE ROLE AND EFFICACY OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

Nephrolithiasis in preterm infants rarely requires surgical management. When it persists despite conservative therapy, treatment options are not clearly defined. We report a single institutional experience with extracorporeal shock wave lithotripsy (ESWL)* for the treatment of these small infants. We treated 8 infants (mean age 13 months) with a history of prematurity and 9 persistent stones with a Dornier HM3 lithotriptor between 1996 and 1999. Mean weight was 7,700 gm. Of the infants 7 had been treated with furosemide for bronchopulmonary dysplasia and 1 presented with multiple anatomical abnormalities. Gantry modification with a wooden platform and polystyrene foam positioning was used for lung and visceral protection. Ureteral stents were placed in 5 patients before ESWL. Renal ultrasonography was performed before, and 2 and a mean of 8 weeks after ESWL. Stone risk factors in our population were investigated through a multispecialty approach. Average stone burden was 47.9 mm.2. A total of 9 sessions of ESWL were required for complete fragmentation of the 9 renal stones. A mean total of 2,100 shocks at a mean 16.1 kV. were administered. One patient with bilateral stones was treated in 2 separate sessions after a 4-week interval. No repeat ESWL sessions or other surgical interventions were required in any patient. Renal ultrasonography demonstrated no post-ESWL morphological changes. Practices leading to a higher incidence of neonatal nephrolithiasis at our institution were also identified. ESWL is effective treatment for nephrolithiasis in small infants. Short-term safety has been established but continued long-term functional followup is essential. Multifactorial etiologies of nephrolithiasis must be identified and modified promptly in the care of preterm infants.

Nefopam Analgesia as a Substitute of Neurolept Analgesia for Extracorporeal Shock Wave Lithotripsy

To the Editor: Pain is an important side effect of extracorporeal shock wave lithotripsy (ESWL). It causes patient discomfort, movements, and tachypnea. We evaluated the efficiency of nefopam hydrochloride, a centrally acting nonnarcotic analgesic, in 197 consecutive patients (mean age 53 yr, range 23–86 yr) treated for renal stones by ESWL, using the piezoelectric EDAP LT-02 lithotriptor (EDAP, Lyon, France). Nefopam (20 mg) was administered IV over 30 min before ESWL. At the end of the session, patients were asked to assess their satisfaction with pain control using a four-point verbal scale. A total of 26.9% of patients reported no pain, 36.5% reported minimal pain, 30.5% moderate but tolerated pain, and 6.1% severe or untolerated pain necessitating interruption of the session. Nefopam was efficient in 94% of cases, ESWL session being conducted with the power and duration planned by the urologist (mean 44 min, range 25–62 min). No hemodynamic changes or oxygen desaturation were noted. The following minor side effects occurred in 14.7% of patients: nausea (8.6%), sedation (5.1%), and vomiting, hypotension, and drowsiness (0.5%). Nefopam is not structurally correlated to nonsteroidal antiinflammatory drugs or morphine-like drugs and so it is free of their serious side effects and contraindications. It inhibits the neuronal uptake of dopamine, serotonin, and noradrenaline in supraspinal and spinal levels, and increases neurotransmission in pain inhibitory serotoninergic descending pathways (1,2). As analgesic requirements during ESWL are difficult to predict, we recommend routine nefopam administration to reduce the incidence of treatment failure and avoid stressful pain experience. Fouad Atallah MD Thérèse Bastside-Heulin MD Kamran Samii MD Pierre Plante MD*

Extracorporeal Shock Wave Lithotripsy in Children

Extracorporeal Shock Wave Lithotripsy in Children

PANCREATIC PLEURAL EFFUSION SUCCESSFULLY TREATED BY ENDOSCOPIC PANCREATIC DUCT DRAINAGE COMBINED WITH EXTRACORPOREAL SHOCK‐WAVE LITHOTRIPSY: REPORT OF A CASE

A 52‐year‐old man was admitted with complaints of dyspnea. Physical examination revealed that the breath sounds were reduced at the left lung. The results of the abdominal examination were normal. Chest radiography showed massive left‐sided pleural effusion. His white blood cell count was 4600/mm3, serum amylase 666 IU/L, serum C‐reactive protein (CRP) 3.7 mg/dL. Thoracentesis yielded bloody fluid with a protein level of 3.7 g/dL and amylase level of 6250 IU/L. Computed tomography showed dilatation of the pancreatic duct with calcifications of the pancreas, mediastinal pancreatic pseudocysts and bilateral pleural effusion. Magnetic resonance cholangiopancreatography demonstrated dilated pancreatic duct with pancreatic calculi and pancreaticopleural fistula. Initial endoscopic retrograde cholangiopancreatography showed obstructing pancreatic calculi of the main pancreatic duct at the head; however, insertion of a naso‐pancreatic drain was unsuccessful. A naso‐pancreatic drain could be placed beyond the site of obstruction following three extracorporeal shock‐wave lithotripsy (ESWL) sessions. Pleural effusion was resolved and the chest tube was removed 5 days following placement of the drain. The naso‐pancreatic drain was replaced with a pancreatic stent 20 days later. Endoscopic retrograde cholangiopancreatography after a total of nine ESWL sessions showed a significant reduction of pancreatic calculi at the head. The pancreatic stent was removed 70 days following stent placement and there has been no recurrence during a follow‐up period of 2 years. We suggest that endoscopic treatment combined with ESWL is a first‐line treatment for pancreatic pleural effusion resulting from obstructing pancreatic calculi, and operation should be reserved as a second‐line treatment.

Prospective Evaluation of Morphology, Function, and Quality of Life After Extracorporeal Shockwave Lithotripsy and Endoscopic Treatment of Chronic Calcific Pancreatitis

Therapeutic endoscopy may be effective in selected patients with chronic calcific pancreatitis (CCP). We prospectively evaluated the early outcome of extracorporeal shockwave lithotripsy (ESWL) in combination with interventional endoscopy, using broad inclusion criteria. A total of 48 consecutive patients (35 male, 13 female) were recruited for ESWL and endoscopic therapy of symptomatic CCP. Symptoms, quality of life, pancreatic morphology and function were assessed before and after. Multiple stones (n = 43), strictures (n = 34), and pancreas divisum (n = 11) were found. A median of 13 ESWL sessions (range 2-74) with a median of 22,100 shockwaves (1,700-150,900) were required. Endoscopic pancreatic sphincterotomy (n = 48), stricture dilation (n = 12), and/or stenting (n = 27) were performed. After therapy, drainage of the pancreatic duct system was achieved in 36, complete stone clearance in 21 patients. Follow-up (n = 38) at 7 months (range 5-9) showed a significant decrease in pancreatic duct diameter (p < 0.001) and pain score (p < 0.0001) whereas complete pain relief was observed in 45% of cases. Several quality of life scores improved significantly. Weight gain occurred in 68% of patients. Normalization of fasting blood glucose and HbA1c levels were observed in four patients, without modifying their treatment. Improvement in pain score correlated with weight gain and decrease in pancreatic duct diameter. Nonalcoholic etiology was associated with a better chance for improvement in pain score and decrease in pancreatic duct diameter. The presence of strictures did not deteriorate the clinical outcome. Besides pain relief, ESWL in combination with interventional endoscopy resulted in pancreatic ductal decompression, weight gain, and improvement in quality of life in a considerable number of patients with advanced CCP.

Prospective evaluation of morphology, function, and quality of life after extracorporeal shockwave lithotripsy and endoscopic treatment of chronic calcific pancreatitis

OBJECTIVE: Therapeutic endoscopy may be effective in selected patients with chronic calcific pancreatitis (CCP). We prospectively evaluated the early outcome of extracorporeal shockwave lithotripsy (ESWL) in combination with interventional endoscopy, using broad inclusion criteria. METHODS: A total of 48 consecutive patients (35 male, 13 female) were recruited for ESWL and endoscopic therapy of symptomatic CCP. Symptoms, quality of life, pancreatic morphology and function were assessed before and after ESWL. RESULTS: Multiple stones (n = 43), strictures (n = 34), and pancreas divisum (n = 11) were found. A median of 13 ESWL sessions (range 2–74) with a median of 22,100 shockwaves (1,700–150,900) were required. Endoscopic pancreatic sphincterotomy (n = 48), stricture dilation (n = 12), and/or stenting (n = 27) were performed. After therapy, drainage of the pancreatic duct system was achieved in 36, complete stone clearance in 21 patients. Follow-up (n = 38) at 7 months (range 5–9) showed a significant decrease in pancreatic duct diameter ( p < 0.001) and pain score ( p < 0.0001) whereas complete pain relief was observed in 45% of cases. Several quality of life scores improved significantly. Weight gain occurred in 68% of patients. Normalization of fasting blood glucose and HbA1c levels were observed in four patients, without modifying their treatment. Improvement in pain score correlated with weight gain and decrease in pancreatic duct diameter. Nonalcoholic etiology was associated with a better chance for improvement in pain score and decrease in pancreatic duct diameter. The presence of strictures did not deteriorate the clinical outcome. CONCLUSIONS: Besides pain relief, ESWL in combination with interventional endoscopy resulted in pancreatic ductal decompression, weight gain, and improvement in quality of life in a considerable number of patients with advanced CCP.

The management of paediatric urolithiasis.

To evaluate the efficacy and safety of the management of paediatric urolithiasis by extracorporeal shock wave lithotripsy (ESWL), endoscopic ureterolithotomy, percutaneous nephrolithotomy (PCNL) and open nephrolithotomy. In a 3-year period (1997-1999), 59 children were treated for urolithiasis and underwent a total of 79 procedures. Thirty-two ESWL sessions were performed in 23 children (mean age 7.4 years, median 6.0). PCNL was undertaken in 30 renal units in 25 children (mean age 6.4 years, median 4.0). Eight patients (mean age 7.8 years, median 5) underwent 17 ureteroscopic procedures, six of which involved the use of a holmium laser. Three children with staghorn calculi underwent open nephrolithotomy under conditions of renal ischaemia and hypothermia. Of the 23 children treated using ESWL, 21 (91%) became stone-free; 17 underwent one ESWL session (74%), three had two sessions and three (13%) had three sessions. All eight patients who underwent ureteroscopy became stone-free. Four patients in whom the stone could not be reached by ureteroscopy initially had a JJ stent inserted, and the stone and stent subsequently removed. Stones were cleared using PCNL in 27 of 30 renal units (90%); three patients who had residual stone fragments were rendered stone-free by ESWL. Two of three children undergoing open nephrolithotomy were stone-free after surgery and the remaining one rendered stone-free with ESWL. Metabolic evaluation showed that 25 of 45 children (55%) had a urinary infection, eight (18%) had hyperoxaluria, three (7%) had hypercalciuria, two (4%) had cystinuria, and no identifiable cause was found in seven (16%). Treatment by a single modality rendered 52 of the 59 children (88%) stone-free; when the different modalities were combined, 57 of 59 patients (97%) were cleared of their stones. Technological advances in ESWL, ureteroscopy and PCNL have had a significant effect on the management of urolithiasis in children, allowing a safe and successful outcome. The comprehensive care of children with urolithiasis should include a full metabolic evaluation. Anatomical anomalies contribute to the complexity of many cases, necessitating a close liaison between adult and paediatric urologists, nephrologists and radiologists to optimize stone management in children.