Long term response to gallstone treatment - Problems and surprises

Objective. To re-evaluate after 5 years the results of a randomised trial o f cholecystectomy and lithotripsy for the treatment of symptomatic gallston es. Design: Late follow-up of a randomised controlled trial. Setting: Teaching hospital, UK. Subjects: 144 of the 179 patients originally randomised. Interventions: Either elective open cholecystectomy under general anaesthes ia or a maximum of 4 sessions of lithotripsy (up to 3000 shocks/session) on consecutive days with no anaesthesia or analgesia. Results: Of the original 87 patients randomised to be treated by lithotrips y, 39 (45%) subsequently underwent cholecystectomy, most of them within 32 months of treatment ("crossover" group). Patients in both main groups had a pronounced reduction in the number of episodes of pain at 5 years and sign ificant reductions in the mean severity scores both on VAS and the McGill r ating. Those in the crossover group had the worst scores. Gastrointestinal symptoms improved in the two main groups, but again the crossover group did least well. Quality of lift: improved significantly over baseline in the t wo main groups, but was much poorer in the crossover group. Conclusions: patients who had primary cholecystectomy were more likely to b e free of pain than those treated by lithotripsy. Lithotripsy Save good sym ptomatic results in 55% of patients, and this was not dependent on clearanc e of stones. Patients who had a cholecystectomy after lithotripsy had the w orst symptomatic results. It is difficult to identify patients who will not benefit from lithotripsy, but the presence of many coexisting symptoms may be an important predictor.