Combination therapy of gallbladder stones using extracorporeal shock waves and bile acids: results in relation to stone diameter and stone number]

420 patients were referred to our center for gallstone lithotripsy. 97 patients (23%) with radiolucent gallbladder stones (total diameter less than or equal to 3 cm) and intact gallbladder function were found suitable for extracorporal shock-wave lithotripsy. Disintegration of gallbladder stones was achieved in 92 of the 97 patients (95%). Chenodeoxycholic acid and ursodeoxycholic acid were used as adjuvant litholytic therapy. The therapeutic results were evaluated cumulatively in 90 patients after a follow-up of 10 months. 80% of patients with solitary stones (less than or equal to 20 mm in diameter (n = 46) had a stone-free gallbladder, whereas patients with solitary stones greater than 2 cm, less than or equal to 3 cm in diameter (n = 20) and multiple stones (n = 22) became stone-free in only 28% (p less than 0.01). During the observation period 21 patients (23%) experienced biliary colics, 2 (2%) mild pancreatitis, 2 (2%) showed fragment impaction in the common bile duct, and 17 (19%) displayed transient microscopic hematuria. Our results confirm previous studies showing that solitary stones sized up to 2 cm in diameter represent the best suited subgroup for extracorporeal shock-wave lithotripsy.     

Extracorporeal shock-wave lithotripsy and ursodiol versus ursodiol alone in the treatment of gallstones.

The efficacy and occurrence of adverse effects after two forms of treatment were compared in 111 patients with biliary colic and radiolucent gallstones in this prospective, nonrandomized study. Fifty-four patients received extracorporeal shock-wave lithotripsy (ESL) plus ursodiol, and 57 patients received ursodiol alone. Among patients with a single stone (5-20 mm in size), no patient treated with ursodiol alone had a stone-free gallbladder at 6 or 12 months after treatment; of those treated with ESL plus ursodiol, 15 of 24 patients (63%) had a stone-free gallbladder at 6 months and 17 of 20 patients (85%) at 12 months. For patients with multiple stones (with an aggregate diameter of less than or equal to 30 mm), the incidence of a stone-free gallbladder was 2 of 43 patients (5%) at 6 months and 8 of 35 patients (23%) at 12 months in the ursodiol treatment group. In the ESL plus ursodiol group, the incidence of a stone-free gallbladder was 7 of 22 patients (32%) at 6 months and 9 of 20 patients (45%) at 12 months. Two patients in the ESL plus ursodiol group (4%) and 13 patients in the ursodiol group (24%) underwent cholecystectomy. Both patients in the ESL plus ursodiol therapy and 4 patients in the ursodiol group had emergency cholecystectomies because of acute cholecystitis. The remaining 9 patients in the ursodiol group had elective cholecystectomies. In this nonrandomized, prospective study, ESL plus ursodiol treatment produced stone-free gallbladders at a faster rate than ursodiol alone in patients with either single or multiple gallstones.     

Safety and Efficacy of High kV Biliary Lithotripsy: Preliminary Experience

Despite intense interest in laparoscopic cholecystectomy, biliary lithotripsy (BL), by avoiding the need for general anesthesia, could remain a useful alternative in approximately 10% of patients with symptomatic gallstones. The poor stone clearance rates reported by the Dornier National Biliary Lithotripsy Study has led to disenchantment with biliary lithotripsy. However, the results may reflect the relatively low kV (18.7 +/- 1.7) used. We have compared symptomatic gallbladder stone/cholecystolithiasis patients with one to five stones of aggregate diameter < 60 mm treated with one to three sessions on an MPLS 9000 (Dornier) lithotripter at moderate kV (22.7 +/- 1.7 kV; mean number of shocks 1473 +/- 356) with a similar group treated with high kV (26 kV, mean number of shocks 1357 +/- 507). Ultrasound stone diameter measurements were made pre- and post-BL; 12-wk results are reported. Treatment safety was assessed by recording adverse experiences and serum, urine, hematology, and chemistry. For patients with single stones, the high kV treatment took significantly (p < 0.05) less time (74 +/- 30 min) than moderate kV treatment (118 +/- 33 min). At 3 months, the moderate kV-treated single-stone group had a residual maximum fragment size of 3.2 +/- 3.3 mm versus 1.8 +/- 2.3 mm in the high kV-treated single-stone group. The 3-month stone-free rate for patients with single stones treated at high kV was 44% compared with 46% for the moderate kV-treated group (NS). At 1 wk, 11 patients had microscopic or macroscopic hematuria and six patients had mildly elevated liver function tests. At 6 wk, however, all urine and hematological measurements had returned to normal. Two patients suffered pancreatitis, one in each group. High kV BL appears to be safe and, for patients with single stones, gives better fragmentation and takes less time to administer than moderate kV. Whether a high kV treatment protocol can achieve improved long-term stone-free rates remains to be assessed.     

Treatment of gallstones with piezoelectric lithotripsy and oral bile acids. A multicenter study

The efficacy of the combination of piezoelectric lithotripsy and oral bile acids in the treatment of gallbladder stones was assessed. Three hundred and sixty-three patients with symptomatic radiolucent gallstones in functioning gallbladder were treated in five medical centers using the same protocol with the EDAP LT 01 lithotripter. No anesthesia, analgesia or sedation was used. After one session of lithotripsy, fragmentation was observed in 89% of the patients, and satisfactory fragmentation (fragments less than or equal to 5 mm) in 29%. The satisfactory fragmentation rate was higher in patients with solitary stones less than or equal to 20 mm than in patients with solitary stones 21-35 mm or multiple stones (p less than 0.001). After multiple sessions (mean 1.6 session/patient, range 1-5) the overall rate of satisfactory fragmentation was 50%. After 12 months on oral bile acid therapy, complete clearance of the gallbladder was observed in 69% of patients with solitary stones less than or equal to 20 mm, 25% of patients with solitary stones 21-35 mm and 37% of patients with multiple stones. No complication was observed during the lithotripsy. During follow-up under bile acid therapy, there were five complications (1.4%): four patients had acute cholecystitis and one had mild, self-limited pancreatitis. We conclude that piezoelectric lithotripsy with the EDAP lithotripter is a safe and effective treatment which can be performed in outpatients. Satisfactory fragmentation and rapid disappearance of stones are obtained mainly in patients with solitary stones less than or equal to 20 mm.     

Total biliary protein, mucus glycoproteins, cyclic-AMP, and apolipoproteins in the gallbladder bile of patients with cholesterol stones and stone-free controls.

The concentrations of total protein, mucus glycoprotein, cyclic-AMP, and apolipoproteins A-I, A-II, and B were determined in the gallbladder bile of patients with cholesterol gallbladder stones and in stone-free controls. The total protein content was significantly increased in gallstone patients (2.03 +/- 0.6 versus 1.31 +/- 0.67 mg/ml; p less than 0.05), as was the mucus glycoprotein concentration (380 +/- 88.5 versus 128 +/- 57.2 micrograms/ml; p less than 0.05). The cyclic-AMP concentration in the gallbladder fluid was increased up to 91 +/- 20 pmol/100 microliters in the gallstone subjects, as compared with 46 +/- 26 pmol/100 microliters (p less than 0.01) in stone-free controls. Cyclic-AMP concentrations correlated positively with the glycoprotein content of the bile in cholesterol gallstone patients (r = 0.66; p less than 0.05). The apolipoprotein concentrations were determined by the radial immundiffusion technique. The corresponding values for patients with stones and controls were 7.5 +/- 0.8 versus 3.0 +/- 0.8 for Apo A-I (p less than 0.025), 10.4 +/- 0.6 versus 6.3 +/- 1.3 for Apo A-II (p less than 0.02), and 1.9 +/- 0.5 versus 1.6 +/- 0.2 mg/dl for Apo B (NS), respectively. Biliary proteins probably play an important role in the nucleation process during the pathogenesis of cholesterol gallbladder stones.     

Noninvasive therapy of gallbladder calculi with a radiopaque rim.

Safety and efficacy of shock-wave lithotripsy and bile acid dissolution therapy of patients with gallbladder calculi with a radiopaque rim were evaluated. Eighty-six patients with symptomatic solitary stones were treated by this noninvasive therapy and were followed up to 18 months. Three different lithotripsy treatment modalities were used. Up to 1600 shock wave discharges were applied. Patients in group A (n = 20) were treated with an electrohydraulic water-bath lithotripter at a discharge voltage of 18 +/- 1 kV (mean +/- SD), group B patients (n = 25) were treated with an electrohydraulic water-cushion lithotripter at 19 +/- 2 kV, and group C patients were treated (n = 41) with the same lithotripter at 22 +/- 2 kV. Five to eight months after lithotripsy, 15% in group A were free of fragments compared with only 4% in group B (NS vs. group A), and 38% in group C had no stones (NS vs. group A; P = 0.007 vs. B). Thirteen to eighteen months after lithotripsy, the respective results were 59% in group A, 37% in group B (NS vs. group A), and 68% in group C (NS vs. group A; P = 0.05 vs. group B). Patients with fragments of less than or equal to 3 mm in diameter showed significantly better fragment clearance than those with larger fragments. The frequency of adverse effects was not significantly different between the three groups. Biliary colic occurred in 43% of the patients and mild biliary pancreatitis in 3 patients. Endoscopic sphincterotomy was required in 1 patient, and elective cholecystectomy was performed in 6 patients. Using a water-cushion lithotripter at high-power setting, selected patients with solitary gallbladder stones with a radiopaque rim may be treated safely and successfully by shock-wave lithotripsy combined with bile acid dissolution therapy.     

Fragmentation of gallstones using extracorporeal shock waves: an in vitro study

Eighty in vitro experiments were performed with single (n = 51) or multiple (n = 29) gallstones in order to find out which parameters are of prime importance for their disintegration by extracorporeal shock waves. A Dornier lithotripter and an upper limit of 1,500 discharges were employed. Although computed tomography density was significantly lower in cholesterol stones than in the noncholesterol stones (p less than 0.0001) and although the latter were significantly more often radiopaque (p less than 0.0001), we found no clear-cut correlation between the cholesterol content or computed tomography density and the degree of fragmentation of the stones. The most important variable which limited successful disintegration was the total stone volume. In stones with a mean total volume of 0.83 ml +/- 0.25 S.E. (diameter for single stones = 11.5 +/- 0.9 mm), none of the fragments exceeded 2 mm, whereas in stones with a mean volume of 3.6 ml +/- 0.64 (diameter = 17.2 +/- 1.5 mm) at least one fragment larger than 2 mm remained (p less than 0.002). Under the in vitro conditions, fragmentation was similar in multiple and solitary stones, provided the volume of the stones was comparable. These data show that, in general, the number and size of the stones, i.e. their total volume, and much less significantly their chemical composition are the major determinants of fragmentation by extracorporeal shock waves.     

A Clinical Comparison of an Electrohydraulic and a Piezoelectric Shockwave Lithotripter in Gallstone Therapy

The aim of this prospective, randomized study was to compare two second-generation lithotripters based on different physical principles in patients with gallbladder stones at a single lithotripsy center under the same clinical conditions. Sixty patients with one to three symptomatic gallbladder stones were selected for lithotripsy, either with an electrohydraulic or a piezoelectric device. With both lithotripters, treatment was performed under standard conditions (prone position, sonographic monitoring, sedoanalgesia if necessary, up to 3000 pulses/session, retreatments (maximum, two) if fragments >4 mm, concomitant oral chemolitholysis). if no fragmentation could be obtained in the first session, the other lithotripter was used for the following treatments. The two groups did not differ significantly with regard to the anthropometric data or number and size of stones. In contrast to piezoelectric lithotripsy (0%), with the electrohydraulic lithotripter, iv analgesics and sedatives were necessary in all treatments (100%); however, in 11/53 treatments (21%), patients did not tolerate the full session despite maximum medication. The treatment time was nearly twice as long with electrohydraulic (56 ± 22 min) than with piezoelectric lithotripsy (31 ± 8 min) ( p < 0.001). With the electrohydraulic lithotripter, used in 20% of the patients, no fragmentation was seen after the first session, and therapeutically adequate fragmentation (≤4 mm) occurred in only 33%. In contrast, with the piezoelectric lithotripter, the stones were disintegrated in all patients ( p < 0.05); in 50% a maximum fragment size ≤4 mm was measured after the first treatment. Whereas in the first months after lithotripsy, stone-free rates were higher with piezoelectric lithotripsy (43% vs. 25% after 1 month: 47% vs. 38% after 2 months; 60% vs. 48% after 4 months; NS), rates of complete stone disappearance were equally high in both groups after 12 months (82%).     

Gallstone disappearance after extracorporeal lithotripsy and oral bile acid dissolution

Extracorporeal shock-wave cholelithotripsy was carried out in 135 symptomatic patients with radiolucent gallstones, followed by oral bile acid dissolution to assess the resultant stone disappearance rates. Fragmentation was satisfactory (all fragments less than 5 mm in diameter) in 34 patients (25%) after a single session of lithotripsy, and in 65 (48%) after multiple sessions. The overall satisfactory fragmentation rate was significantly higher in patients with single stones less than or equal to 20 mm in diameter when compared with those with larger solitary stones (71% vs. 38%, p less than 0.05), as it also was in all subjects with solitary stones when compared with those with multiple stones (60% vs. 34%, p less than 0.05). After 6, 9, and 12 mo of oral bile acid treatment, the stone-free rates were significantly higher in patients with satisfactory than in those with partial fragmentation (55% vs. 0%, 80% vs. 29%, and 90% vs. 33%, respectively; p less than 0.05). Only 1 of the 7 patients who had previously undergone endoscopic sphincterotomy for concomitant choledocholithiasis was free of stones after 1 yr of dissolution. During dissolution therapy, of the 102 patients in whom fragmentation had occurred, 1 (1%) developed mild acute pancreatitis, 23 (23%) suffered attacks of biliary colic, and 6 (6%) required cholecystectomy. We conclude that the result of fragmentation appears to be a major determinant of the success and rapidity of subsequent oral bile acid dissolution, and that when satisfactory, it allows for complete stone disappearance in most patients within the following year. A comparison of the present results with those of previous original studies suggests that to achieve such satisfactory fragmentation, patients should be selected on the basis of their stone characteristics, which optimally should present as solitary gallbladder calculi less than 20 mm in diameter. Furthermore, real-time ultrasonographic monitoring should be used during lithotripsy with a transducer centered along the shock-wave axis. Despite the innocuousness of the shock waves, the incidence of fragment migration and its possible complications, in our experience, emphasizes the need to restrict at present this nonoperative approach to the treatment of symptomatic gallstone disease.     

Optimized extracorporeal shockwave lithotripsy of gallbladder calculi: a prospective randomized therapy comparison

Is "pulverization" or "fragmentation" the best endpoint of extracorporeal shock wave application in ESWL of gallbladder stones? Has gallbladder motility a potential for the prevention of stone recurrence? METHODS: Prospective, monocentric study with randomization between the conventional treatment strategy (endpoint of shock wave application: fragments < or = 4 mm, concomitant oral chemolitholysis) and an intensified treatment strategy (endpoint of shock wave application: Pulverization, no chemolitholysis). Prevention of stone recurrence: At least once per month for one hour after a meal standardized position (back position, lowered chest). RESULTS: 34 patients, age 46 +/- 14 years (27 women, seven men) were included (F-ESWL: n = 18; P-ESWL: n = 16). Gallbladder motility, number, size and CT-measured calcifications of stones were comparable for both groups. P-ESWL patients received more shock wave pulses than F-ESWL patients and more treatment sessions. P-ESWL resulted in a better fragmentation and pulverization of stones was reached significantly more often (p < 0.05). The time period for stone clearance was significantly depending on the fragmentation result (pulverization: 0.7 months vs. fragments < or = 4 mm: 6.6 months vs. fragments > or = 4 mm: 8.0 months; p < 0.01). The stone free rate after twelve months was 87.5% for P-ESWL and 72.2% for F-ESWL (n.s.) and correlated significantly with the fragmentation result (p < 0.01). Pain sensations during stone clearance were significantly reduced by P-ESWL. Stonefree patients were followed up for 30 +/- 13 months, the total recurrence rate was 7.1%. CONCLUSIONS: Aiming for pulverization of gallbladder stones by means of intensified extracorporeal shock wave application is at least equal or in tendency superior compared to disintegration to fragements < or = 4 mm. Gallbladder motility might be useful to prevent gallstone recurrence after successful ESWL.     

Efficacy of chenodeoxycholic acid and ursodeoxycholic acid for lowering cholesterol saturation index of gallbladder in patients with a sphincterotomy

After endoscopic retrograde sphincterotomy, patients with an intact gallbladder are at risk for developing symptoms or complications of gallbladder stones. Medical dissolution of such stones would be desirable, especially in elderly patients with an increased surgical risk. However, sphincterotomy alters emptying dynamics of the gallbladder and markedly reduces bile salt pool size, effects that may alter response to chenodeoxycholic acid or ursodeoxycholic acid treatment. Studying two groups of 5 patients with an intact gallbladder after endoscopic retrograde sphincterotomy, we found that 15 mg/kg.day of chenodeoxycholic acid increased the mean (+/- SEM) biliary percentage of chenodeoxycholic acid from 35.5% +/- 4.0% to 88.8% +/- 1.9% (p less than 0.01) and decreased the mean saturation index of gallbladder bile from 1.02 +/- 0.22 to 0.55 +/- 0.08 (p less than 0.05). Ursodeoxycholic acid (10 mg/kg.day) increased the mean biliary percentage of ursodeoxycholic acid from 5.6% +/- 1.5% to 44.7% +/- 5.8% (p less than 0.01) and decreased the mean saturation index of gallbladder bile from 1.04 +/- 0.25 to 0.57 +/- 0.03 (p less than 0.05). A long-term trial of bile acid treatment in sphincterotomy patients with stones in an intact gallbladder is needed.     

Piezoelectric lithotripsy in the treatment of symptomatic gallstone patients. A 12-month follow-up

Between January and May 1989, 65 patients with symptomatic gallbladder stones were treated with extracorporeal piezoelectric lithotripsy (EPL) and supplementary dissolution therapy with oral bile acids. In 98% of the patients, fragmentation of stones was achieved. On average, each patient received 3.18 treatments. In addition to attacks of colic and asymptomatic changes in laboratory parameters, one hematoma of the gallbladder and one of the liver were observed, together with pancreatitis and cholecystitis in two patients each. During the follow-up period, three patients developed symptomatic bile duct stones. An endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy was performed on four occasions, while one female patient had to undergo urgent cholecystectomy for inflammation of the gallbladder and empyema. Six months after the initial treatment, 36 (55%) patients were free of stones, while the stone-free rate after 12 months was 64.5% (41 of 65). Ninety percent of the patients with a solitary stone less than or equal to 2 cm in diameter became stonefree within a year. Extracorporeal piezoelectric lithotripsy is clearly a feasible procedure for the treatment of certain gallstone patients.     

The Munich Gallbladder Lithotripsy Study. Results of the first 5 years with 711 patients

OBJECTIVE: To evaluate the long-term results of three types of shock wave treatment in patients with radiolucent gallbladder stones. DESIGN: Cohort study. SETTING: Single-center trial. PATIENTS: Of 5824 patients with gallstones, 19% were eligible; 711 patients were treated. INTERVENTIONS: Patients received extracorporeal shock wave lithotripsy as well as adjuvant therapy with bile acids. RESULTS: Lithotripsy was done in three ways, using a water-tank lithotriptor (group A), a water-cushion lithotriptor at low energy levels (group B), and a water-cushion lithotriptor at high energy levels (group C). The rate of complete fragment clearance 9 to 12 months after lithotripsy was done differed significantly among the three groups: Among patients with single stones of 20 mm or less in diameter, the rate of fragment clearance for group A was 76%; for group B, it was 60%; and for group C, it was 83% (P = 0.03). Among patients with single stones of 21 to 30 mm, the rate of fragment clearance for group A was 63%; for group B, it was 32%; and for group C, it was 58% (P less than 0.005). Among patients with two or three stones, the rate of fragment clearance for group A was 38%; for group B, it was 16%; and for group C, it was 46% (P = 0.01). Patients with fragments of 3 mm or less 24 hours after lithotripsy was done showed a higher probability of fragment disappearance than did those with larger fragments (P less than 0.001). The clearance rate was higher in patients who were compliant than in those who were noncompliant with bile acid therapy (P less than 0.001). Adverse effects included liver hematoma in 1 patients, biliary pain attacks in 253 patients (36%), mild biliary pancreatitis in 13 patients (2%), and cholestasis in 7 patients (1%). Elective cholecystectomy was done in 16 patients (2%), and endoscopic sphincterotomy was done in 4 patients (1%). CONCLUSIONS: The rate of complete disappearance of stones after shock wave therapy depends on the size and the number of the initial stones, the diameter of the largest fragment, and the mode of shock wave treatment. Adjuvant therapy with bile acids appears to be important for complete fragment clearance.     

A ten-year prospective study on gallbladder stone recurrence after successful extracorporeal shock-wave lithotripsy

OBJECTIVE: The risk of recurrence has limited the acceptability of conservative therapies of gallbladder stones. The aim of the present study was to determine the long-term rate of stone recurrence and its risk factors after successful extracorporeal shock-wave lithotripsy (ESWL). MATERIAL AND METHODS: The study comprised a prospective ultrasound follow-up at yearly intervals or whenever biliary pain was reported. A total of 192 consecutive patients (primary single stones, n=159; primary 2 or 3 stones, n=33) were followed for up to 11.2 years after becoming stone-free and after termination of adjuvant treatment with ursodeoxycholic acid (UDCA). RESULTS: Eighty-four patients developed recurrent stones after a median of 2.6 years (maximum?=?8.8 years). The 108 patients without recurrence were followed for a median of 6.7 years (maximum=11.2 years). By actuarial analysis, the cumulative recurrence rates for these 192 stone-free patients were 27%+/-3%, 41%+/-4% and 54%+/-4% (observed +/-SE) at 3, 5 and 10 years, respectively. Cox's regression analysis was used to identify the presence of slight calcification in the primary stone(s) as a protective feature against recurrence (p=0.03). CONCLUSIONS: 1) The risk of recurrence continues to increase over time, and although it rises less steeply after 5 years, it does not reach a plateau until at least 10 years. 2) Having had slightly calcified stone(s) seems to be associated with a reduced risk of recurrence and might signal a "burnt out" lithogenic process. 3) The long-term results are unsatisfactory and ESWL of gallbladder stones should be offered only in special cases.     

Pancreaticobiliary ductal union in biliary diseases. An endoscopic retrograde cholangiopancreatographic study

To assess whether the anatomy of the pancreaticobiliary ductal drainage into the duodenum has any relationship with biliary diseases we analyzed 259 endoscopic retrograde cholangiopancreatograms. These included 102 normal examinations (control group), 95 patients with gallstone disease, and 21 patients with carcinoma of the gallbladder. In the control group, 64 (63%) subjects had a common channel and 38 (37%) had separated openings for the common bile duct and the main pancreatic duct. By contrast, the prevalence rate of a common channel was significantly lower in gallstone disease [28 (30%); p less than 0.001]. No such difference, compared with controls, was observed in patients with carcinoma of the gallbladder. The length of the common channel in the control group (mean +/- SD, 4.7 +/- 2.5 mm) was similar to that in gallstone disease (4.6 +/- 2.6 mm). However, patients with carcinoma of the gallbladder had a significantly longer common channel (8.3 +/- 4 mm; p less than 0.001) compared with the control group. An abnormally long common channel (greater than or equal to 8 mm) was seen more frequently in carcinoma of the gallbladder (8 of 21; 38%) compared with normal subjects (3 of 102; 3%) and patients with gallstones (1 of 95; 1%); the difference was highly significant (p less than 0.001 for each). These observations suggest a close association between the anatomy of the distal ends of the common bile duct and main pancreatic duct and the development of gallstones and carcinoma of the gallbladder.     

ESWL and oral dissolution therapy

With the aim of identifying the criteria that have a decisive influence on the success of treatment of gallstones with ESWL and oral dissolution therapy, we investigated, in 117 patients, the stone-free rate as a function of sex, age, weight quotient, number of stones, total stone volume, and gallbladder function. The following inclusion criteria were applied: (1) the Munich criteria, (2) a follow-up period of at least 12 months, or (3) freedom from stones irrespective of the duration of the period of follow-up. Although, owing to the small number of cases involved, no significantly differing results were seen in the parameters investigated, clear tendencies were indeed observed. While age, sex, and weight quotient qppear to have no influence on the stone-free rate, the number of stones, total stone volume, and gallbladder function do appear to have an effect on the results of treatment. Patients with solitary stones not more than 20 mm in diameter, and patients with a small total stone volume and good gallbladder function would appear to have the best chance of becoming stone-free within a short period of time, irrespective of age, sex, or girth.     

Endoscopic biliary endoprosthesis in elderly patients with large bile duct stones: long-term follow-up.

OBJECTIVE: To assess the long-term evolution of elderly patients with large or impacted bile duct stones, treated by an endoscopic biliary endoprosthesis. DESIGN: Case series. SETTING: Tertiary care center. PATIENTS: Twenty-three patients with a mean (+/- SD) age of 86 +/- 5 years (range, 77-97 years). On admission, 96% were highly symptomatic. These patients represent 8.4% of a group of 273 elderly patients (greater than or equal to 70 years old) with choledocholithiasis treated by endoscopic sphincterotomy between November 1984 and May 1989. INTERVENTION: Endoscopic insertion of a biliary endoprosthesis. RESULTS: Eight-seven percent (20/23) remained completely free of biliary symptoms and died of unrelated illness (48%) after a mean follow-up of 23 months or are still alive (39%) with a mean follow-up of 52 months. In four cases, this asymptomatic evolution now extends for more than 5 years. CONCLUSION: Insertion of a biliary endoprosthesis offers an effective method for long-term treatment of non-extractable biliary stones in elderly patients.     

111In platelet imaging of left ventricular thrombi. Predictive value for systemic emboli

To determine whether a positive indium 111 platelet image for a left ventricular thrombus, which indicates ongoing thrombogenic activity, predicts an increased risk of systemic embolization, we compared the embolic rate in 34 patients with positive 111In platelet images with that in 69 patients with negative images during a mean follow-up of 38 +/- 31 (+/- SD) months after platelet imaging. The positive and negative image groups were similar with respect to age (59 +/- 11 vs. 62 +/- 10 years), prevalence of previous infarction (94% vs. 78%, p less than 0.05), time from last infarction (28 +/- 51 vs. 33 +/- 47 months), ejection fraction (29 +/- 14 vs. 33 +/- 14), long-term or paroxysmal atrial fibrillation (15% vs. 26%), warfarin therapy during follow-up (26% vs. 20%), platelet-inhibitory therapy during follow-up (50% vs. 33%), injected 111In dose (330 +/- 92 vs. 344 +/- 118 microCi), and latest imaging time (greater than or equal to 48 hours in all patients). During follow-up, embolic events occurred in 21% (seven of 34) of patients with positive platelet images for left ventricular thrombi as compared with 3% (two of 69) of patients with negative images (p = 0.002). By actuarial methods, at 42 months after platelet imaging, only 86% of patients with positive images were embolus free as compared with 98% of patients with negative images (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Oral dissolution therapy for cholelithiasis: mix and match

The authors conducted a prospective, randomized trial of chenodeoxycholic and ursodeoxycholic acid versus ursodeoxycholic acid alone in patients with cholelithiasis to determine their efficacy for dissolution of gallstones. One hundred and twenty patients with radiolucent gallstones, less than or equal to 15 mm and who had a functioning gallbladder were enrolled. The patients were divided into two groups based on the diameter of their largest stones. Seventy patients had stones larger than 5 mm but less than 15 mm, whereas 50 patients had stones that measured 5 mm or less. The patients were randomly assigned to treatment with chenodeoxycholic acid plus ursodeoxycholic acid (5 mm/kg of each) or ursodeoxycholic acid (10 mm/kg) alone. Oral cholecystography, plain abdominal x-rays, and ultrasonography of the gallbladder were done at 6, 12, and 24 months. Dissolution was deemed to be complete if not stones were visualized on two examinations. partial dissolution was defined as a 50% reduction in stone size and/or number. Stones that were not detected by cholecystography but still detected during ultrasonography were considered to be partially dissolved. Plasma triglycerides, serum cholesterol, HDL, and serologic liver function tests were determined at 1, 3, 6, 12, 18, and 24 months. In a select group of patients, bile-rich duodenal aspirates were aspirated and analyzed for biliary lipid contents. In the group with small stones, defined as less than or equal to 5 mm, complete stone dissolution occurred significantly more often utilizing combination therapy at 6 months (52% vs 24%), and this trend persisted, although no longer significant, at 12 and 24 months. Combination therapy also achieved an improved rate of dissolution for large stones within 6 months; however, this did not persist at 12 and 24 months. Although not statistically significant, stone calcification occurred less often with combined therapy. All treatment regimens were well tolerated, with only minor changes in bowel habits and mild elevations in serum transaminase levels. Serum lipid levels did not change with either therapy. The authors concluded that the combination of chenodeoxycholic acid and ursodeoxycholic acid was the preferred therapy for gallstone dissolution, because it dissolves stones more rapidly, with a lower incidence of stone calcifications, and thus might reduce the long-term cost of treatment.     

Corticosteroid treatment for inflammatory bowel disease in pediatric patients increases intraocular pressure.

Intraocular pressure (IOP) was measured in 54 pediatric patients (aged 7-21 years) with inflammatory bowel disease (IBD) who were treated with oral prednisone for 1-104 months. The difference in mean IOP between the treated patients (mean +/- SD, 15.62 +/- 4.11 mm Hg) and 55 age-matched controls (13.83 +/- 2.42 mm Hg) was statistically significant (P = 0.007). The IBD patients were classified as group I, IOP less than or equal to 19 mm Hg in both eyes, and group II, IOP greater than or equal to 20 mm Hg in either eye. Twelve of the 54 patients (22.2%) and none of the controls had IOP greater than or equal to 20 mm Hg (P less than 0.001). Seventeen of the 54 patients (31.5%) were characterized as "steroid responders" (IOP of greater than or equal to 20 mm Hg, change in IOP of greater than or equal to 6 mm Hg between visits, or difference in IOP of greater than or equal to 6 mm Hg between the two eyes). When the dose of prednisone was reduced to 0-10 mg/day 30 days or more before measurement, 9 steroid responders showed a decrease in IOP to within 2 SD of the mean control IOP; 7 of the 9 showed a decrease in IOP of greater than or equal to 6 mm Hg. These observations indicate that while prednisone is a causative factor in increasing the IOP, susceptibility to average doses of prednisone is highly variable, and patients need to be monitored on an individual basis. Because IBD is a chronic disorder that requires prolonged corticosteroid treatment, these children are at risk of developing steroid-induced glaucoma. Careful ophthalmologic monitoring of pediatric IBD patients, as well as of other pediatric patients who receive corticosteroid therapy, is recommended.