Lithotripsy is the crushing of gallstones.

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

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

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Indications for lithotripsy

Lithotripsy can be performed if the following conditions are met:

• uncomplicated course of cholelithiasis;
• preserved contractility of the gallbladder (60% or more) according to oral cholecystography and ultrasound;
• radiolucent (cholesterol) or calcified stones only at the periphery;
• number of stones: optimal - one, acceptable - 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 with single cholesterol stones not exceeding 2 cm in size. In this case, the preserved motor function of the gallbladder and the patency of the cystic duct (as well as the common bile duct) are the determining conditions for the passage of small fragments of the destroyed stone with bile.

How is lithotripsy performed?

The shock wave is generated by various physical methods: using an electrohydraulic, piezoelectric or magnetically restrictive generator (lithotripter). When using different types of lithotripters, the shock wave is generated underwater and transmitted to the patient's body by means of a water-filled bag that is in close contact with the skin treated with a special gel. In order to increase the effectiveness of the impact on stones and reduce the damaging effect on the patient's organs and tissues, the shock wave is focused.

Efficiency of lithotripsy

The effectiveness of lithotripsy is usually assessed by the number of patients with a calculus-free gallbladder after 6 and 12 months (repeated ultrasound is performed). When optimal conditions for lithotripsy are observed and the method is combined with subsequent use of litholytic agents, the effectiveness of treatment is, according to various authors, from 45 to 80%.

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

Situations with concretions in the common bile duct remaining after cholecystectomy should be considered separately. If attempts at endoscopic lithoextraction have failed or are impossible, lithotripsy may be entirely justified.

Contraindications to lithotripsy

Absolute contraindications to the method are:

• blood clotting disorder or taking medications that affect the hemostasis system;
• the presence of vascular aneurysms or cysts along the path of the shock wave;
• cholecystitis, pancreatitis, peptic ulcer;
• obstruction of the bile ducts, “disconnected” gallbladder;
• the presence of an artificial cardiac pacemaker;
• three or more stones, the total diameter of which exceeds 2 cm (calcium stones);
• pregnancy.

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Complications of lithotripsy

Among the complications accompanying the use of lithotripsy, the following should be noted:

• biliary colic (in approximately 30-50% of patients), acute cholecystitis, pancreatitis (in 2-3% of patients);
• transient increase in bilirubin and transaminase levels (1-2% of patients);
• micro- and macrohematuria (3-5% of observations);
• pain in the lumbar region;
• choledocholithiasis with the development of mechanical jaundice;
• hematomas of the liver, gallbladder, right kidney (1% of cases).

A special problem is the release of small fragments of stones from the bile ducts formed as a result of shock wave lithotripsy. Some authors discuss the advisability of additional papillosphincterotomy (necessary in approximately 1% of patients). The use of lithotripsy to crush large "driven" stones in the CBD before papillosphincterotomy is described. Given the possibility, albeit rare, of developing cholangitis and biliary sepsis (in 2-4% of cases), the use of antibiotic prophylaxis before the lithotripsy session and antibiotic therapy after it is indicated. To increase the effectiveness of lithotripsy, the method should be accompanied by subsequent treatment with litholytic drugs.

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