Lithotripsy: crushing gallstones

For the first time in clinical practice, lithotripsy in patients with cholelithiasis was applied in 1985 by T. Sauerbruch et al.

The method is used according to strict indications in the form of an independent method of treating cholecystolithiasis or in combination with oral litholytic therapy in order to improve the efficiency of the latter.

[1], [2], [3], [4], [5]

Indications for lithotripsy

Carrying out of a lithotripsy is possible at observance of following conditions:

• uncomplicated course of cholelithiasis;
• the preserved contractility of the gallbladder (by 60% or more) according to oral cholecystography and ultrasound;
• X-ray translucent (cholesterol) or calcified only on periphery stones;
• the number of concrements: optimally - one, permissible - no more than three;
• The size of the stone is no more than 2 cm in diameter (sometimes up to 3 cm).

Clinical practice shows that the greatest effectiveness of lithotripsy is observed in single cholesterol concrements, not exceeding 2 cm in size. Moreover, the preserved motor function of the gallbladder and the permeability of the cystic duct (as well as the GI) are the determining conditions for the departure from the bile of small fragments of the destroyed calculus .

How is lithotripsy performed?

The formation of a shock wave is performed by various physical methods: with the help of an electrohydraulic, piezoelectric or magnetically restrictive generator (lithotriptor). When different types of lithotriptors are used, a shock wave is generated under water and transmitted to the patient's body through a water-filled bag tightly in contact with the skin treated with a special gel. In order to increase the effectiveness of exposure to concrements and reduce the damaging effect on the organs and tissues of the patient, the shock wave is focused.

The effectiveness of lithotripsy

The effectiveness of lithotripsy is assessed, as a rule, according to the number of patients with free of obstruction of the HP at 6 and 12 months (repeated ultrasound is performed). Under optimal conditions for lithotripsy and combination of the method with the subsequent use of litholytic agents, the effectiveness of treatment is, according to different authors, from 45 to 80%.

At the same time, rather narrow indications, the presence of a certain number of contraindications and complications make the application of extracorporeal shock wave lithotripsy very limited. Moreover, it would be superfluous to emphasize that in the case of lithotripsy, the efforts of specialists are aimed at eliminating the effect of the disease, and not on its cause, besides successful fragmentation does not exclude repeated kamie formation with a frequency of up to 10% annually as in litholytic therapy.

Separately, we should consider the situation with concrements in the common bile duct, left after cholecystectomy. If endoscopic lithoextraction attempts are not successful or impossible, lithotripsy can be fully justified.

Contraindications to lithotripsy

Absolute contraindications to the method are:

• violation of blood clotting or taking drugs that affect the hemostasis system;
• presence of vascular aneurysms or cysts along the path of shock wave propagation;
• cholecystitis, pancreatitis, peptic ulcer;
• violation of the patency of the bile ducts, the "disconnected" gallbladder;
• presence of an artificial pacemaker;
• three stones or more, the total diameter of which exceeds 2 cm calcium stones;
• pregnancy.

[6], [7], [8], [9], [10], [11], [12], [13],

Complications of lithotripsy

Among the complications that accompany the use of lithotripsy, it should be noted:

• biliary colic (approximately in 30-50% of patients), acute cholecystitis, pancreatitis (in 2-3% of patients);
• transient increase in the level of bilirubin, transaminases (1-2% of patients);
• micro- and macrohematuria (3-5% of observations);
• pain in the lumbar region;
• Choledocholithiasis with the development of mechanical jaundice;
• hematoma of the liver, ZHP, right kidney (1% of observations).

A particular problem is the release of bile ducts from small fragments of stones formed as a result of shock wave lithotripsy. Some authors discuss the question of the advisability of additional papillosphincterotomy (needed in about 1% of patients). The use of lithotripsy for crushing large "pinned" concrements in the OCG before the papillosphincterotomy is described. Considering the possibility, although rare, of the development of cholangitis and biliary sepsis (in 2-4% of cases), the use of antibiotic prophylaxis before the lithotripsy session and antibiotic therapy after it is shown. To increase the effectiveness of lithotripsy, the method should be followed by subsequent treatment with litholytic drugs.

[14], [15], [16], [17], [18], [19],