Shock Wave Lithotripsy Of Gallstones Research Articles

SAGES video classics

A review of surgical history is always enlightening. To hear presentations and read the words of the innovators who lived through the era of endoscopy and laparoscopy introduction is even more invigorating. In this edition of Surgical Endoscopy, two of our endoscopic innovators have written cogent accounts of their involvement during the early days of endoscopy and laparoscopy. Dr. Ken Forde recognized the advantages of the colonoscope early on for the location of colonic bleeding. Although thought to be a relative contraindication, in the hands of experts, the colonoscope can be a key tool in the identification of colonic bleeding. It is quite appropriate that this account be published in Surgical Endoscopy because of Dr. Forde’s leadership and his love for the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). His original publication in Gastrointestinal Endoscopy, read by many gastroenterologists, also gave a clear message that surgeons should be the leaders in endoscopic diagnosis, especially for patients who might need surgical intervention. The second account by Jacques Perissat recounts his early involvement in laparoscopy, especially in recognizing that the gallbladder could be approached safely and that large incisions could be avoided during cholecystectomy. He recounts how he worked with many of the leaders of endoscopy in Europe and progressed from shock wave lithotripsy of gallstones to the removal of gallstones without cholecystectomy. Inevitably, Dr. Perissat recognized that cholecystectomy could be safely performed, and using sound scientific and teaching principles, he became the emissary from Europe to help usher in the era of laparoscopic cholecystectomy. I was fortunate to be in Louisville, Kentucky April 1989 when Dr. Perissat showed the now famous video of his laparoscopic technique. A reprise of this video accompanied his beautiful presentation at the Video Classics session during the SAGES meeting in Phoenix in April 2009. We owe a lot to the giants of endoscopy and laparoscopy. For those who have not been fortunate enough to live through the exciting era during which these techniques were introduced, the opportunity to read the accounts of those seminal events and to see the original videos continues to rekindle that initial excitement.

Sonography and biliary extracorporeal shockwave lithotripsy (ESWL)

Ultrasound is an indispensable tool for preliminary diagnosis ("filter function"), during treatment ("monitoring function") and in the follow-up examinations ("follow-up function") after shock-wave lithotripsy of gallstones. It permits rapid and reliable assessment of the therapeutic outcome and early identification of complications, which present-day experience has shown to be rare.

Extracorporeal shock wave lithotripsy of gallstones: 20th anniversary of the first treatment

Twenty years ago, in January 1985, extracorporeal shock wave lithotripsy (ESWL) was first applied successfully in a patient with gallbladder stones. In the following years, the conditions which influence the success rate of ESWL have been extensively investigated. It was shown that the characteristics of the stones, gallbladder emptying and the degree of stone fragmentation are the most important factors which determine the clearance of all fragments from the gallbladder after ESWL. Severe side effects, such as biliary pancreatitis and liver haematoma, were found to be rare and no deaths related to the procedure have been reported. One or more episodes of biliary pain were observed in about one third of patients within the first 3-4 months after ESWL. Follow-up studies after successful treatment, however, have shown that stone recurrence is considerable, limiting the use of ESWL as a non-invasive therapeutic option. Stone recurrence varies between different subgroups of patients indicating that gallbladder motor function and other less well defined factors may be of importance. The recurrence of stones after ESWL is one of the reasons why laparoscopic cholecystectomy has become the standard treatment of symptomatic gallbladder stones today. ESWL has kept its role only in the treatment of bile duct stones resistant to endoscopic extraction. Unless stone recurrence can be decreased by better patient selection and/or other measures to prevent gallstone recurrence, ESWL of gallbladder stones has little chance of surviving.

Extracorporeal shock wave lithotripsy of gallstones revisited: current status and future promises.

The improvement and refinement of extracorporeal shock wave lithotripsy (ESWL) has made this non-invasive treatment modality not only more effective, but also applicable to a larger population of gallstone patients. It can be performed safely on an outpatient basis. Advances in lithotripsy technology have made it possible to fragment stones into very small, sand-like particles (pulverization), which clear the gall-bladder faster than large fragments. Recent studies provide evidence that adjuvant bile acids may not be necessary in most cases in which pulverization is achieved. Good gall-bladder emptying appears both to promote the clearance of gallstones after ESWL and to decrease their recurrence. Although generally found to be more expensive than surgery if bile acids are used, ESWL should be cost-effective, as bile acids may not be necessary in all patients. Elderly patients with radiolucent, solitary and less than 30 mm gallstones can particularly benefit from lithotripsy.

Extracorporeal Shock Wave Lithotripsy of Gallstones in Different Biles and Water in vitro

Twenty-four gallstones were fragmented by extracorporeal shock wave lithotripsy (ESWL) to compare the influence of three different biles (bovine bile, human bile, synthetic bile) and water on the rapidity of fragmentation. Four groups of comparable stones were used for lithotripsy in vitro. The stones were collected from 6 patients, four nearly identical 'sister' stones from each patient. The number of shock waves required for adequate fragmentation (fragments < or = 4 mm) was measured for comparison. Overall highly significant differences were found for the four different 'biles' with regard to the number of shock waves required for adequate fragmentation. Using synthetic bile, which was artificially composed according to a textbook on hepatology, significantly more shock waves were necessary for fragmentation compared to the use of water, bovine bile or human bile. On the other hand, no significant difference between water and human bile could be registered. We conclude that the number of shock waves required for adequate lithotripsy is influenced by the composition of bile in which the stone is fragmented. Possibly results of ESWL can be improved by manipulation of the bile.

Gallbladder emptying is an important factor in fragment disappearance after shock wave lithotripsy

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.

Extracorporeal Shock Wave Lithotripsy of Gallstones after Biliary Attack

Extracorporeal Shock Wave Lithotripsy of Gallstones after Biliary Attack

Patient controlled analgesia for extracorporeal shock wave lithotripsy of gallstones

Sixty patients undergoing shock wave lithotripsy of gallbladder stones (ESWL) were randomly assigned to receive alfentanil either by infusion controlled by the attending anesthesiologist (standard treatment group, n = 31) or by analgesia controlled by the patient (PCA group, n = 29). Patients using PCA were allowed to self-administer 0.25 mg of alfentanil i.v. every minute as required. Data collected during treatment included the total dose of drug required, transcutaneous pCO 2 values, verbal pain and sedation scores, visual analogue scale (VAS) patient satisfaction scores, and the incidence of nausea or vomiting. PCA patients used less alfentanil than the standard treatment group (PCA group: 12.8 μg/kg; standard treatment group: 44.3 μg/kg; mean values, P = 0.0001), tolerated significantly higher pain intensities and self-administered the narcotic only to moderate levels of pain but not to pronounced analgesia. Standard treatment patients reported lower levels of pain, were more sedated ( P < 0.05) and showed significantly higher transcutaneous pCO 2 values. There was a trend towards a lower incidence of nausea or vomiting in PCA patients without reaching statistical significance. No significant difference with regard to patient satisfaction with pain relief could be demonstrated. Self-administered alfentanil during ESWL of gallbladder stones provided adequate analgesia with minimal side effects and high patient satisfaction. ESWL may represent a new and useful indication for PCA.

Extracorporeal gallbladder lithotripsy: technology, practical methods, results and current value

Extracorporeal shock wave lithotripsy of gallstones is a safe and well-tolerated procedure. Patients are now treated without general anesthesia and, increasingly, on an outpatient basis. Skin petechiae and transient hematuria are the most common side effects. Episodes of biliary colic are common in the follow-up period, but more serious adverse side effects such as cholecystitis and pancreatitis are distinctly uncommon. It is estimated that only 15% to 20% of all patients with symptomatic cholelithiasis are suitable lithotripsy candidates. As our knowledge of the procedure grows, it seems clear that the best results are obtained in patients with solitary radiolucent stones less than or equal to 20 mm, with stone-free rates at 12 months above 80%, for this selected group of patients. Adjuvant oral bile-acid dissolution therapy should be used in conjunction with gallstone lithotripsy. Gallstone recurrence remains to be established by clinical studies. Therapy for gallstones in 1991 has to be reevaluated by an interdisciplinary approach, taking into account not only open cholecystectomy, but also other modalities such as medical dissolution, laparoscopic surgery, percutaneous cholecystolithotomy and extra-corporeal shock wave lithotripsy. The appeal of the laparoscopic approach will substantially reduce the pool of patients for lithotripsy. Nevertheless, lithotripsy will continue to be a viable treatment option for patients with a single radiolucent stone. It is an outpatient procedure and doesn't require any incision or general anesthesia.

Shock wave lithotripsy of gallstones: results and 12-month follow-up in 174 patients.

At the authors' institution, as part of the on-going Dornier National Biliary Lithotripsy Study, 174 patients with gallstones were randomly assigned to receive either ursodeoxycholic acid (UDCA) or placebo for 6 months after undergoing extracorporeal shock wave lithotripsy (ESWL). Six weeks after ESWL, 40 (23%) patients were re-treated for gallstone fragments larger than 5 mm in diameter. No significant difference in the UDCA- and placebo-treated patients was noted. The overall 6- and 12-month stone-free rates for all patients with initially noncalcified stones were as follows: UDCA patients, 31% and 36%, respectively, and placebo patients, 21% and 23%, respectively (P less than .05). In patients with a single, noncalcified gallstone that was at most 20 mm in diameter, the 12-month stone-free rates were as follows: UDCA patients, 60%, and placebo patients, 33% (P less than .01). Patients with noncalcified stones that were 11-20 mm in diameter who were treated with UDCA had a higher rate of stone clearance than placebo patients. At 6 months, the authors' previous study demonstrated no significant difference in the two groups of patients. However, the stone-free rate at 12 months was noted to be significantly higher for patients with a single, noncalcified stone that was at most 20 mm in diameter begun on UDCA than for all other groups of patients.

Detection of Tissue Injury After Extracorporeal Shockwave Lithotripsy of Gallstones

We evaluated seven patients undergoing gallstone lithotripsy for evidence of hepatic or renal trauma after each of 10 lithotripsy treatments. Postlithotripsy magnetic resonance imaging (MRI) and sonography showed no evidence of hepatic or renal injury as compared with baseline studies. Four treatments resulted in sonographic evidence of gaseous hepatic microbubbles (analogous to "the bends") due to cavitation effects of the shockwaves. Three of these four treatments produced serum glutamicoxaloacetic transaminase and -pyruvic transaminase elevation. One patient had microscopic hematuria. Minimal tissue damage results from gallstone lithotripsy. MRI and ultrasound, performed after lithotripsy, appear to be less sensitive than transaminasemia in detecting this low-grade injury.

Extracorporeal shock wave lithotripsy of gallstones: results and 6-month follow-up in 141 patients.

A study of biliary shock wave lithotripsy of gallstones sponsored by Dornier Medical Systems, Munich, began in the United States in May 1988 to evaluate the efficacy and safety of extracorporeal shock wave lithotripsy (ESWL) and the need for adjunctive therapy with ursodeoxycholic acid (UDCA). One hundred forty-one symptomatic patients with one to three gallstones 5-30 mm in diameter were randomized to treatment. One week before ESWL, patients were given either UDCA or placebo. This treatment was continued for 6 months. All patients underwent follow-up at predetermined intervals. According to the protocol, re-treatment for fragments larger than 5 mm in diameter could be performed only at 6 weeks; 26 (18%) of the 141 patients were retreated. At 6 months, the stone-free rates for single stones were as follows: patients with noncalcified stones receiving UDCA, 29%; patients with noncalcified stones receiving placebo, 24%; and patients with partially calcified stones receiving either UDCA or placebo, 6%. No significant difference was noted between the UDCA and placebo groups. At 6 months, the stone-free rates in patients with single, noncalcified stones 20 mm or less in diameter were 40% (UDCA) and 32% (placebo), which is superior to rates for those with solitary, noncalcified gallstones 21-30 mm in diameter and those with two or three stones.

Extracorporeal shockwave lithotripsy of gallstones and the importance of operative cholangiography during laparoscopic cholecystectomy

Our institute participated in a national study. We had 68 patients (two-thirds had solitary and one-third multiple gallstone calculi). Our extracorporeal lithotripsy results at 9-18 months' follow-up showed 25% to be free of stone (fragment). Forty-four percent required a second session. This technique has limitations and needs further improvement in the aiming devices available and the size of fragments in order to be useful to a larger group of patients. Laparoscopic cholecystectomy is a new modality for endoscopic removal of the stone-filled gallbladder. It can be performed safely in a well-selected group of elective cases. It represents a final cure because the diseased stone-containing gallbladder is removed. Patients have distinct advantages: less postoperative pain, a short hospital stay, and early return to work. Intraoperative cholangiography is of help to define the anatomy. Surgeons need to be competent in laparoscopy before using this technique to perform endoscopic cholecystectomy. It will play a dominant role in the future treatment of symptomatic cholelithiasis.

Simulation of gallstone fragments by cavitation bubbles during extracorporeal shock wave lithotripsy: physical basis and in vitro demonstration.

During extracorporeal shock wave lithotripsy of gallstones, sonography often shows a swirling pattern of echogenic foci shortly after the application of shock waves. This effect has been thought to represent gallstone fragments in suspension. However, evidence suggests that this finding is in part due to cavitation, a physical phenomenon associated with the formation or movement of gas bubbles in the fluid-filled gallbladder. Condoms filled with degassed water and five human bile specimens were positioned in the focus of an MPL 9000 lithotriptor (Dornier Medical Systems, Munich). A solitary nonradiopaque gallstone was then added to a bile-filled condom, and the sonographic pattern was observed before and after fragmentation. The mean clearance time of the cavitation bubbles was 4 seconds for degassed water and 22 seconds for human bile. Gallstone fragments were distinguished from cavitation bubbles by their prolonged settling time (up to 30 minutes) along the dependent gallbladder wall.

Walter B. Cannon lecture. Shock-wave lithotripsy of gallstones.

Aspect physique des ondes de choc. La procedure de lithotripsie, la therapeutique adjuvante. La selection des patients. Resultats: la fragmentation. La clearance. Les incidents. Les recidives. Traitement des calculs des voies biliaires

Pain Control during Extracorporeal Shock Wave Lithotripsy of Gallstones by Titrated Alfentanil Infusion

Pain Control during Extracorporeal Shock Wave Lithotripsy of Gallstones by Titrated Alfentanil Infusion

Extracorporeal shock wave lithotripsy of gallstones: Objectives, current limitations, and preliminary in vitro and in vivo observations

Surgical removal of gallstones is performed about 500 000 times per year in the United States. Although the usual cost ranges from $5000 to more than $10 000 per patient, the operative mortality is less than 1% for otherwise healthy persons. Nonsurgical dissolution of gallstones is often possible, but many gallstones contain calcium compounds that slow or prevent dissolution using the direct content cholesterol solvent, methyl tertbutyl ether (MTBE). Extracorporeal shock wave lithotripsy (ESL) has potential clinical utility for facilitating dissolution and possibly allowing spontaneous or induced passage of small fragments via the bile ducts and intestines. Obstacles to be overcome include predictable fragmentation of multiple stones up to 3 cm in diameter so that all particles are small enough to be rapidly dissolved or pass safely through the bile ducts (⩽ 3 mm). This must be achieved using biologically tolerable shock wave dosages without requiring general anesthesia within one or two treatment sessions. Acute and chronic safety, patient acceptance, and cost must be competitive with surgical treatment. Initial experience suggests that only solitary noncalcified stones (10% of patients with stones) have a high probability of success using ESL plus oral bile acid dissolution therapy. Improving ESL technology and direct contact fragment dissolution using MTBE should increase the clinical utility of shock wave lithotripsy of gallstones.