THE ROLE OF EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY IN THE TREATMENT OFSYMPTOMATIC CHOLELITHIASIS

Objectives: To determine the effectiveness of extracorporeal shock-wav e lithotripsy (ESWL) and adjuvant bile-salt therapy for the treatment of symptomatic cholelithiasis. Design: A prospective case study. Follo w-up ranged from 3 to 54 months. Setting: A university teaching hospit al. Patients: Two hundred and twenty-three patients with symptomatic c holelithiasis, a gallbladder that opacified at oral cholecystography a nd three or fewer radiolucent stones with a maximum total dimension of 3 cm. Of these patients, 197 were given bile salts (ursodeoxycholic a cid or chenodeoxycholic acid, 8 to 10 mg/kg daily) and underwent ESWL. Twenty-eight were excluded because of noncompliance with the protocol or treatment failure before termination of the ESWL procedure. Interv ention: ESWL with a piezoelectric lithotripter. Main Outcome Measures: The success rate of the intervention, the causes of failure, associat ed complications and the recurrence rate of cholelithiasis. Results: O f the 197 patients who underwent ESWL, 85 (43%) were free of stones af ter treatment. Treatment failure was caused by the following: unsatisf actory fragmentation (9%), increase in fragment size during bile-salt therapy (8%), severe diarrhea due to bile salts (3%), nonvisualization of fragments after the first ESWL (3%), acute cholecystitis (2%), per sistence of small fragments at the end of the treatment protocol (2%) and acute pancreatitis (0.5%). Complications included biliary colic (2 1%), diarrhea (15%), acute cholecystitis (2.5%), acute pancreatitis (2 %), macroscopic hematuria (2%), perirenal hematoma (0.5%) and vagal sh ock (0.5%). The recurrence rate was 18%. Causes of noncompliance with treatment (26%) were the length of treatment, the occurrence of biliar y colic during this period and the high cost of bile salts. Conclusion : ESWL with bile salts as treatment for symptomatic cholelithiasis is not recommended for routine use.