Gall stone pulverisation strategy in patients treated with extracorporeal lithotripsy and follow up results of maintenance treatment with ursodeoxycholic acid.

Abstract

Between November 1988 and July 1992 70 patients with radiolucent gall stones were treated with extracorporeal lithotripsy (ESL) and ursodeoxycholic acid (UDCA; mean (SD) dose 11-2 (1-9) mg/kg/day). Fifty three patients have been followed for one year. One week after lithotripsy, 30-6% had completely eliminated all stone fragments from the gall bladder and one year later 93*9% were free of stones. Three factors were considered important in achieving these results. 'Pulverisation' of the stone -that is, its fragmentation into echogenic dust (crystalline aggregates, some few hundred > in size) or particles similar to grains of sand, smaller than 1 mm in diameter, or both, is required. Secondly, dust and particles were rapidly eliminated, strongly suggesting a mechanical elimination process by physiological gall bladder contractions. Thirdly, there must be chemical dissolution with biliary acids. This therapeutic approach gave excellent results without causing any clinically relevant side effects. The first 20 patients who became free of stones after ESL were given oral bile acid maintenance treatment -300 mg/ day of UDCA at bedtime, for two years. All were asymptomatic and none had suffered a recurrence after two years. In four patients, crystalline aggregates, detected in gall bladder bile by ultrasound, were subsequently dissolved between one and three months after resuming a full dose regimen of UDCA. (Gut 1994; 35: 117-12 Results of studies on extracorporeal lithotripsy (ESL) of gall stones in which patients have been followed up for seven years have often proved to be unsatisfactory and at times discordant. Despite this we believe that ESL is an extremely effective method of treating gall stones and that these negative results may result from the following factors that are unrelated to the procedure: (1) Use of equipment developed for kidney stone dissolution and improperly adapted to gall stone treatment; (2) Use of shock waves that are too low in pressure and too few in number; (3) Therapeutic strategy tending towards stone fragmentation followed by chemical dissolution with bile acids lasting even long periods of time.This trial aimed to determine whether by perfecting the technique of biliary lithotripsy, the procedure would prove to be an effective method of treating gall stones. For this purpose it was necessary to verify:(1) Whether by using shock waves adequate in pressure and in number it would be possible to achieve 'pulverisation' of stones into crystalline aggregates or particles the size of grains of sand, or both.(2) Whether by achieving this pulverisation it would be possible to achieve safer and more rapid elimination of the resulting microfragments.(3) Eliminating stones followed by maintenance treatment while preserving the gall bladder would be sufficient to avoid stone recurrence. Methods PATIENTSBetween November 1988 and July 1992, 70 patients with radiolucent gall stones were treated with a lithotripter equipped with an underwater spark-gap for shock wave generation (Dornier MPL...

Costs and Effectiveness of Extracorporeal Gallbladder Stone Shock Wave Lithotripsy Versus Laparoscopic Cholecystectomy: A Randomized Clinical Trial

“…Satisfactory fragmentation (defined by the persistence of fragments of no more than 5 mm (5)) seems to approximate 40-60%, although heterogeneity in reporting makes conclusions somewhat uncertain (5,126,128,(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149)(150). Electrohydraulic generators have on average required fewer sessions than the other two generator types to achieve this endpoint (5).…”

“…Electrohydraulic generators have on average required fewer sessions than the other two generator types to achieve this endpoint (5). It would appear that the shock waves themselves are safe though they cause reversible enzymatie rises (126,(135)(136)(137)(138)(139)(140)(141)(142)(143)(144)(145)(146)(147)(148)(149)(150) Although in vitro data suggest the basis for a possible expansion of selection criteria on the basis of CT scan appearance (116), small, solitary, uncalcified stones are the most likely to fragment satisfactorily, and will do so 70% of the time (5). The resulting fragments are then treated by oral bile acids, which have been shown to accelerate the dissolution rate (151).…”

Repeated piezoelectric lithotripsy for gallstones with and without ursodeoxycholic acid dissolution: A multicenter study

“…Namely, this concept of extracorporeal shockwave lithotripsy appears to be positioned as an extension of the concept of bile acid dissolution therapy. 3,12 On the other hand, a modified treatment procedure, "pulverization" has been reported more recently by Boscaini et al 19 and by Soehendra et al 2~ This involves the same procedure as our repeated lithotripsy with no limit to the total number of shockwaves and treatment sessions, and is carried out to achieve particularly fine disintegration of the stones. The pulverized fragments appear to be evacuated spontaneously and rapidly from the gallbladder, without the administration of bile acid agents.…”

Physical laws of cholesterol gallstone fragmentation

“…A threshold energy exists for the stones below which no further fragmentation takes place. According to previous experiments, fragment layers in front of still intact stones or larger stone pieces may attenuate the acoustic energy to these levels [20][21][22].…”

“…According to previous experiments, fragment layers in front of still intact stones or larger stone pieces may attenuate the acoustic energy to these levels [20][21][22]. According to previous experiments, fragment layers in front of still intact stones or larger stone pieces may attenuate the acoustic energy to these levels [20][21][22].…”