Extracorporeal Shock Wave Lithotripsy of Pancreatic Duct Stones

Chronic calcifying pancreatitis presents a major clinical problem, often requiring extensive surgery. Extracorporeal shock wave lithotripsy (ESWL) offers a new therapeutic option. We applied ESWL after endoscopic sphincterotomy of the pancreatic orifice in eight patients with impacted pancreatic duct stones. An electromagnetic lithotriptor (Siemens Lithostar, Erlangen, FRG) was used. Patients were treated in prone position under fluoroscopic control. A mean of 6,813 shock waves (range 1,500-10,000) was delivered in one or two sessions. Disintegration of stones was achieved in 6/8 patients, initial relief of pain in 7/8 patients, and total clearance of the pancreatic duct in 3/8 patients. One patient had an exacerbation of her pancreatitis one day after ESWL, which resolved rapidly with medical treatment. No other complications were observed. Four of five patients with fragmented stones had no abdominal complaints at follow-up (mean 17 months, range 3-27). Three patients in whom ESWL was not completely successful (two without and one with partial fragmentation) underwent an operation according to Puestow. Two of them still have abdominal complaints after surgery. From these data, we conclude that ESWL of pancreatic duct stones is a promising new alternative for surgery, when endoscopic stone extraction fails.     

Electromagnetic Shock Wave Lithotripsy of Gallbladder Stones: A Wide Range of Inclusion Criteria

From April 1988 until November 1990, 83 patients with symptomatic gallbladder stones were treated in the University Hospital "Dijkzigt" Rotterdam with extracorporeal shock wave lithotripsy (ESWL) followed by oral administration of bile acids (urso- and chenodeoxycholic acid). According to our inclusion criteria, patients with up to 10 stones without any limit to the size of the stone(s) were accepted for treatment. On average, these patients underwent two sessions of ESWL with an electromagnetic lithotriptor (Lithostar and Lithostar Plus, Siemens AG, Erlangen, Germany). Fragmentation of stones was achieved in 70/83 (84% patients). The best results were achieved in patients with a solitary gallstone (50% of these patients were stone-free 12 months after ESWL). Four percent of the patients with two to three stones, and 12% of the patients with four to 10 stones were free of stones 12 months after ESWL. Twenty-eight (34%) patients suffered from biliary colics after ESWL, and three patients (3.5%) developed pancreatitis. The administration of oral bile acids was complicated by transient diarrhoea in 15 (18%) patients. ESWL followed by oral bile acid therapy is a relatively effective and safe therapy for a highly select population of patients with gallbladder stones, which can be performed on an outpatient basis. Although the results for multiple stones were poor, the usage of wide inclusion criteria (up to 10 stones of any size) did not affect the success rate of ESWL for multiple stones.     

Stenting and Extracorporeal Shock Wave Lithotripsy in Chronic Pancreatitis

Background: Early observational studies of endoscopic treatment and extracorporeal shock wave lithotripsy (ESWL) reported considerable or complete relief of pain in 50%-80% of patients with chronic pancreatitis. There is no consensus on the measurement of pain, making comparison of observational studies difficult, and little attention has been paid to the type and amount of analgesics used by patients before and after decompressive treatment. Methods: We performed a retrospective study of all patients with chronic pancreatitis and large-duct disease and receiving decompressing treatment between 1 November 1994 and 31 July 1999. Primary parameters were type and amount of analgesics used. Results: Forty-nine patients with chronic pancreatitis and large-duct disease received stenting of the pancreatic duct (28 patients), ESWL (6 patients) or both (15 patients). After a median follow-up of 21 months, 35% of all patients were pain-free and a further 6% were not using analgesics. Seven patients no longer needed opioids during follow-up, but five other patients needed addition of opioids to treatment. The median opioid dose among opioid-dependent patients rose slightly (9%). The median increase of weight after treatment was 1 kg per year. Conclusion: After decompressive treatment of patients with chronic pancreatitis and large-duct disease, we observed a small increase in weight and a small reduction in the number of opioid users. The changes may not be different from the natural course of the disease.     

Medical and Economic Aspects of Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is the method of choice for most renal and ureteral calculi. However, endoscopic procedures such as ureteroscopy or percutaneous nephrolithotomy are being more and more performed as primary treatment alternatives in clinical routine. This development may result from the sometimes unsatisfying results of ESWL. While this is often explained by a lower efficacy of last-generation machines, an often unrecognized explanation is the impact of a less well trained urologist. To achieve best results it is mandatory that fundamental knowledge about shock wave physics and disintegration mechanisms are available. In Germany, the reimbursement system between outpatient and inpatient departments is totally separate. This leads to difficulties in clinical practice. We believe that patients at risk for complications, such as ureteral stones, urinary tract infections or high age, benefit from inpatient treatment, while uncomplicated renal stones can safely be treated on an outpatient basis. Regular application and training of ESWL will aid an optimization of its results and acceptance.     

Combined Percutaneous Balloon Dilation and Extracorporeal Shock Wave Lithotripsy for Treatment of Biliary Stricture and Common Bile Duct Stones

We report a case of cholangitis, liver ahscess, and common bile duct stones in a patient with a benign stricture at a choledochojejunal anastomosis, 3 yr after a complicated duodenohemipancreatectomy. Because surgical reintervention seemed inappropriate, a percutaneous transhepatic balloon dilation was performed after temporary internal-external biliary drainage. Extra-corporeal Shockwave lithotripsy (ESWL) was successfully applied to fragment all common bile duct stones, with suhsequent spontaneous evacuation of all stone fragments through the dilated bilioenteric anastomosis. Only one similar case report has been published before (1), though with a different sequence of therapeutic modalities. Moreover, according to our literature review, this is the first report of ESWL of common bile duct stones by means of the Dornier Compact Lithotriptor (Dornier, Germany) with electromagnetic Shockwave source.     

Incidence and Significance of Biliary Stricture in Chronic Pancreatitis Patients Undergoing Extracorporeal Shock Wave Lithotripsy for Obstructing Pancreatic Duct Stones

Background/AimsThis study assessed the significance of biliary stricture in symptomatic chronic pancreatitis patients requiring extracorporeal shock wave lithotripsy (ESWL) and endoscopic retrograde cholangiopancreatography (ERCP) to remove obstructing pancreatic calculi.MethodsA total of 97 patients underwent ESWL followed by ERCP to remove pancreatic calculi between October 2014 and October 2017 at Virginia Mason Medical Center. Significant biliary stricture (SBS) was defined as a stricture with upstream dilation on computed tomography scan or magnetic resonance cholangiopancreatography scans accompanied by cholestasis and/or cholangitis. SBS was initially managed by either a plastic stent or fully covered self-expandable metallic stent (fcSEMS). If the stricture did not resolve, the stent was replaced with either multiple plastic stents or another fcSEMS. Data were collected by retrospectively reviewing the medical records.ResultsBiliary strictures were noted in approximately one-third of patients (34/97, 35%) undergoing ESWL for pancreatic calculi. Approximately one-third of the biliary strictures (11/34, 32%) were SBS. Pseudocysts were more frequently found in those with SBS (36% vs 8%, p=0.02), and all pseudocysts in the SBS group were located in the pancreatic head. The initial stricture resolution rates with fcSEMSs and plastic prostheses were 75% and 29%, respectively. The overall success rate for stricture resolution was 73% (8/11), and the recurrence rate after initial stricture resolution was 25% (2/8).ConclusionsAlthough periductal fibrosis is the main mechanism underlying biliary stricture development in chronic pancreatitis, inflammation induced by obstructing pancreatic calculi, including pseudocysts, is an important contributing factor to SBS formation during the acute phase.     

Extracorporeal Piezoelectric Lithotripsy for Complicated Bile Duct Stones

Today, common bile duct stones are extracted endoscopically. After endoscopic sphincterotomy, nearly 90% of all stones can be removed with a Dormia basket or a mechanical lithotripter. Problems are encountered if there are larger stones or a duct stenosis. New conservative therapies do serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. Stone fragmentation can be achieved by extracorporeal shock wave lithotripsy, and remaining fragments can be removed endoscopically. So far, authors of most reports on the successful disintegration of common bile duct stones used the Dornier lithotripter. Stone localization is thus achieved with x-rays, and the shock waves are generated by an underwater spark discharge. We report on our experiences and results with extracorporeal piezoelectric shock wave lithotripsy (EPL) in 19 patients with complicated bile duct stones. With this lithotripter, stones are visualized by ultrasound, and shock waves are produced by a piezoelectric acoustic generator. Fragmentation was achieved in 84.2%, and complete stone removal in 78.9%. These results show that piezoelectric lithotripsy is also a useful method for the treatment of complicated bile duct stones, as has already been proved for the electrohydraulic- and electromagnetic-generated shock waves systems. However, the renunciation of general anesthesia and the need for analgesia or sedation in only 25% of the treatments render this lithotripter system attractive, especially for elderly and frail patients.     

Predictions and Associations of Cholecystectomy in Patients with Cholecystolithiasis treated with Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy (ESWL) is effective in the treatment of symptomatic cholecystolithiasis in well-selected patients. We analyzed the predictors of cholecystectomy in a large series of gallstone patients after ESWL. This was a retrospective follow-up cohort-study of consecutive patients undergoing ESWL for symptomatic cholecystolithiasis over a 9-year period. It was possible to analyze a total of 297 patients; there were 211 women and 86 men, with a mean age of 52 years (range, 8-81 years). Patients that had been cholecystectomized after ESWL were compared to patients with their gallbladder still in situ and determinants of cholecystemctomy in terms of clinical, stone, and gallbladder parameters and symptoms analyzed. The mean duration of follow-up was 99 months (range, 27-134 months). During follow-up, 106 (36%) patients underwent a cholecystectomy at a mean of 34 months (range, 0-127 months) after ESWL. Histological data showed a normal gallbladder wall in only 4 cases; 101 examinations revealed some kind of (chronic) inflammation, which was not different from histological gallbladder results in patients without prior lithotripsy. Three gallbladder polyps were found, but no carcinoma. Cholecystectomy after ESWL of gallbladder stones was strongly associated with persitent and/or renewed biliary symtoms. Nevertheless, only three of four patients became asymptomatic after CE. Thus, ESWL proved to be a valuable organ-preserving alternative to cholecystectomy in selected patients.     

A Case of Pancreatolithiasis Treated by a Combination of Endoscopic Extraction and Extracorporeal Shock Wave Lithotripsy

We report on the case of a 50-year-old woman with idiopathic chronic calcifying pancreatitis and diabetes. An endoscopic retrograde pancreatography showed a stone with a diameter of 23 mm and multiple small stones in the head of the pancreas. An endoscopic pancreatic sphincterotomy was performed. However, the stone could not be removed endoscopically. So we performed an extracorporeal shock wave lithotripsy (ESWL) using a Tripter X1. The stone was located in the shock wave focus by fluoroscopy. Under intravenous sedation, the patient received 5 ESWL sessions (a total of 11700 shock waves with an energy of 18kv). ESWL permitted stone disintegration and successful endoscopic extraction of the fragments. Complete clearance in the main pancreatic duct was achieved. No severe complications were observed. After treatment, an improvement in the PFD test was seen. ESWL is an effective method for treatment of endoscopically unextractable pancreatic ductal stones.     

Symptoms of Post-Extracorporeal Shock Wave Lithotripsy: Long-term Analysis of Gallstone Patients before and after Successful Shock Wave Lithotripsy

Objective : Considerable infomation is presently available about stone-free rates after extracorporcal shock wave lithotripsy (ESWL) of gallbladder stones. Another important item and one that has been poorly investigated is symptom relief after successful ESWL. The aim of the present trial was to determine the course of biliary and gastrointestinal symptoms after successful ESWL of gallstones. Methods : Ninety patients were followed for an average of 18 months after stone disappearance and discontinuation of oral bile acids. A standardized questionnaire was combined with a clinical and ultrasound examination. Relief of symptoms was correlated to patient characteristics, stone volume, and gallbladder functions. Results : Twelve patients (13%) developed recurrent stones. The probability of stone recurrence was 5.5% (± 2.5%) after 1 yr, 12% (± 4.5%) after 2 yr, and 30.5% (± 9.5%) after 3 yr. Sixty-two of 78 stone-free patients were asymptomatic (80%). Most patients lost their typical biliary symptoms, but statistics also revealed significant differences of nonspecific symptoms and food intolerances pre- and postlithotripsy. Conclusions : This trial has confirmed that patients with symptomatic gallstone disease exhibit a wide spectrum of symptoms, many of which are relieved by ESWL. The fact that at least every fifth patient is not free of symptoms after the gallstone has been removed is in keeping with the findings after cholecystectomy. According to our data, recurrence rate after successful ESWL is higher than previously reported and similar to results after oral litholysis, with no differences between single and multiple stones.     

体外碎石与胆囊收缩功能的关系

为探讨胆囊收缩功能与体外碎石、溶石、排石综合疗效的关系及体外碎石术对胆囊功能的影响．选择经体外碎石疗法治愈且治疗前后均作了口服胆囊造影检查的患者79例．按收缩功能分3组分析，＜1／3（Ⅰ组）29例．≥1／2（Ⅱ组）39例、≥2／3（Ⅲ组）11例。结果显示．治愈后胆囊收缩功能增进率为63．3％；Ⅰ、Ⅱ、Ⅲ组中单个结石消失时间依次为（14．3±133．5）d／例、（80．8±78．6）d／例、（51．8±50．3）d／例．Ⅰ、Ⅲ组比较有显著性差异（P＜0．05）。表明胆囊收缩功能佳者．利于碎石排出．疗程亦短．收缩功能不佳者也有治愈希望。     

Removal of a Large Common Bile Duct Stone Using Endoscopic Balloon Sphincter Dilation and Extracorporeal Shock Wave Lithotripsy

Abstract: Although endoscopic balloon sphincter dilation (EBSD) appears to be an attractive treatment modality, the rate of bile duct clearance is apparently reduced due to limited enlargement of the bile duct opening when the stones are large and/or numerous. We present the case of an 87-year-old woman who developed an extremely large bile duct stone. To crush the stone sufficiently to allow grasping by a mechanical lithotriptor or a basket catheter with the EBSD procedure, extracorporeal shock wave lithotripsy was performed and the fragments were removed successfully.     

The Visceral-to-subcutaneous Adipose Tissue Area Ratio Is Associated with Retreatment in Chronic Pancreatitis Patients with Pancreatolithiasis after Extracorporeal Shock Wave Lithotripsy

Objective Extracorporeal shock wave lithotripsy (ESWL) has been used to treat pancreatolithiasis in patients with chronic pancreatitis (CP), but the high recurrence rate remains challenging. We therefore evaluated the association between body composition parameters and the prediction of retreatment after ESWL. Methods This study retrospectively evaluated 42 patients with CP who had been treated with ESWL between 2008 and 2019 in a single center. Body composition parameters were measured on pretreatment computed tomography images. Patients who underwent repeat ESWL were classified as the retreatment group. Results There were 13 (31.0%) and 29 (69.0%) patients in the retreatment and non-retreatment groups, respectively. The visceral-to-subcutaneous adipose tissue area ratio (VSR) of the retreatment group was significantly lower than that of the non-retreatment group (p=0.016). When divided by the median VSR, 10 of the 20 patients with a VSR of ＜0.85 underwent retreatment, whereas 3 of the 22 patients with a VSR of ≥0.85 underwent retreatment (p=0.019). According to a multivariate analysis, the VSR (p=0.010) and age (p=0.037) were independent factors associated with retreatment after ESWL. Conclusion This study showed that the VSR can predict the retreatment of patients with CP after ESWL.     

Dissolution of Cholesterol Gallbladder Stones with Methyl Tert-Butyl Ether in Patients with Increased Surgical Risk

The safety and efficacy of methyl fert-butyl ether (MTBE) dissolution of cholesterol gallbladder stones were evaluated in 25 patients with increased risk for surgery. Two patients were treated twice. The MTBE was infused and aspirated manually through a percutaneous transhepatic catheter to the gallbladder. The placement of the catheter failed in three patients (11%). In 19 of 24 patients (79%) there was complete dissolution of stones after a mean treatment time of 12.2 h (range, 4.3-19.5 h). In five patients treatment was discontinued before complete dissolution owing to technical problems or side effects. Side effects were nausea, pain, vasovagal reaction, and fever. Fifteen patients were followed up for a mean of 15.7 months after dissolution. Stone recurrence was found in eight patients, five of whom suffered symptomatic relapse. We conclude that dissolution therapy with MTBE is a safe and adequate alternative to surgery in selected high-risk patients.     

低能量体外冲击波治疗缺血性心脏病

缺血性心脏病是导致死亡的主要原因。低能量体外冲击波治疗可以通过增加血管内皮生长因子的mRNA的表达、增加心肌有效灌注和改善左室重塑,从而改善缺血性心脏病患者的症状,减少硝酸甘油的服用,达到治疗缺血性心脏病的目的。