The role of extracorporeal shock-wave lithotripsy in the treatment of symptomatic cholelithiasis.

OBJECTIVES

To determine the effectiveness of extracorporeal shock-wave lithotripsy (ESWL) and adjuvant bile-salt therapy for the treatment of symptomatic cholelithiasis.

DESIGN

A prospective case study. Follow-up ranged from 3 to 54 months.

SETTING

A university teaching hospital.

PATIENTS: Two hundred and twenty-three patients with symptomatic cholelithiasis, a gallbladder that opacified at oral cholecystography and three or fewer radiolucent stones with a maximum total dimension of 3 cm. Of these patients, 197 were given bile salts (ursodeoxycholic acid 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.

INTERVENTION: ESWL with a piezoelectric lithotripter.

MAIN OUTCOME MEASURES: The success rate of the intervention, the causes of failure, associated complications and the recurrence rate of cholelithiasis.

RESULTS

Of the 197 patients who underwent ESWL, 85 (43%) were free of stones after treatment. Treatment failure was caused by the following: unsatisfactory 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%), persistence of small fragments at the end of the treatment protocol (2%) and acute pancreatitis (0.5%). Complications included biliary colic (21%), diarrhea (15%), acute cholecystitis (2.5%), acute pancreatitis (2%), macroscopic hematuria (2%), perirenal hematoma (0.5%) and vagal shock (0.5%). The recurrence rate was 18%. Causes of noncompliance with treatment (26%) were the length of treatment, the occurrence of biliary 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.