Hiromu Mon, MD #{149}Dermot E. Malone, MB Christopher de Gara, MB #{149}Brijendra Rawat, William L. Orovan, MD #{149}Igor Laufer, MD
Frank P. McGrath, MB #{149}William MB #{149}James H. Maher, MD #{149} John #{149} Giles W. Stevenson, MB
Optimizing Gallbladder An International Survey’
T
Rates of stone clearance with extracorporeal shock wave cholecystolithotripsy (biliary lithotripsy [BLI) initially reported by European groups were encouraging. An Amencan multicenter BL study (the Dornier National Biliary Lithotripsy Study [DNBLSI) did not reproduce these results. The BL treatment strategies and 6-month stone clearance rates of six leading European and Japanese centers were compared with those of DNBLS. All foreign centers used adjuvant oral chemolitholysis and greater shock wave energies from the same lithotriptor as that in DNBLS. Six months after BL, the stone clearance rates at all six centers were higher than those of DNBLS. There were no significant differences in complication rates between centers. These findings suggest that the poor results of DNBLS were chiefly due to the use of low kilovoltage and few BL sessions. Increased energy levels and a fragment size end point of less than 5 mm optimize BL. Despite the popularity of laparoscopic cholecystectomy, BL can be recognized as a successful treatment alternative for patients with a low burden of radiolucent stones.
terms:
Gallbladder, 762.1299
.
Gallbladder,
calculi,
interventional Lithotripsy
years.
While
remains
1992;
open
the
MATERIALS
standard,
challeng-
and
ing this position. Both require general anesthesia, however, and have associated morbidity and mortality. Extracorporeal shock wave bithotripsy
is successful
renal stones treatment of et ab in 1986 studies have and efficacy
in the
treatment
tripsy (BL) (2-7). BL treatment cobs and stone clearance rates
sent
protovary
(8). This
tionab
Bibiary
[DNBLS])
study
(the
Dornier
Lithotripsy
reported
Na-
Study
6-month
stone-
at 6 months
had
been
reported for a similar stone burden by a group using the same lithotriptor (2,4). The purpose of this survey was to record the results obtained in centers in Europe and Japan, to compare
762.289
procedure,
with
identify strategies.
184:735-739
those
of DNBLS,
successful,
safe
and
principal
Three
1990).
its to three Stuttgart)
investigator
of the authors
German institutions,
institution,
and
institution.
Wuppertal,
one
9000 was at each
made
(Herne, one
by
Interna-
(Munich,
used the Dornier MPL A detailed questionnaire
to the
center.
patient survey literature
site vis-
Munich, and Italian (Rome)
Japanese
(Fukuoka)
Germany,
was
the
sixth center in this survey. Results published by two of these centers are also inin this survey
selection energy
report questions
(4,7). related
to patient
criteria, the level of shock used, the number of shock
administered, treatments,
the maximum BL end-point
adjuvant
oral
bile
acids,
wave waves
number of criteria, use of
and
pre-
and
post-BL imaging methods. Major and minor complications that followed BL were also recorded. The stone-free rates after 6-, 12-, and 18-month follow-up for solitary
and multiple stones were requested. The data were entered into a data base (Data Ease 4.2; DataEase International, Turnbulb, Conn), and the results were compared
free rates of approximately 30% in patients with a single radiobucent stone less than 20 mm in diameter who received adjuvant ursodeoxycholic acid (8). In Europe, about 70% clearance
sufficient
at the Third
BL Symposium
cluded The
considerably between institutions. An American mubticenter BL study performed with a Dornier MPL 9000 (Dornier Medizintechnik, Germering, Germany) electrohydraulic bithotriptor failed to duplicate European results
of presentations
Each center lithotriptor.
and was first used in the gallstones by Sauerbruch (1). Since then, numerous demonstrated the safety of gallbladder stone litho-
and
were selected for this of a review of published
tional
of
METHODS
that had standardized
protocols
numbers means
laparoscopic
is seriously
AND
Six BL centers treatment
chobecystectomy
chobecystectomy
these Radiology
Lithotripsy:
management options for symptomatic gallbladder stones changed radically in recent
stone
Index
Stone
HE
have
E. Torres, MD Paul Whelan, MD
#{149}
to
BL treatment
with
the
DNBLS
only
trial
using
findings. “intent
DNBLS
was
to treat”
the
analysis
for the calculation of results (cases of patients who were randomized in the “ursodeoxychobic acid and BL” arm but did not undergo BL were regarded as treatment failures). For comparative purposes, the shock wave energy bevels used predominantly ters were
during categorized
moderate
(20-24
BL in the different as low (16-19 kV),
or high
(26
cenkV),
kV).
RESULTS
i
From
the Medical
College
of Oita,
McMaster University Medical Centre, F.P.M., BR., G.W.S.); Emory University, Ontario, Canada (C.d.G.); University
Ontario, From
Canada the
1991
(J.P.W., W.L.O.); RSNA
scientific
Oita,
Japan
(H.M.);
Department
of Diagnostic
the
Imaging,
1200 Main
St W, Hamilton, Ont, Canada L8N 315 (D.E.M., Atlanta (WET.); Henderson General Hospital, Hamilton, of Iowa, Iowa City OHM.); StJoseph’s Hospital, Hamilton,
and Hospital
assembly.
of the University
Received
December
of Pennsylvania, 6, 1991;
revision
Philadelphia requested
January
The patient selection criteria and BL treatment protocols of the six
centers
and
in Table
Abbreviations: DNBLS Study.
reprint
requests
to D.E.M.
summarized
300 patients
had
3,
Dornier Medical C RSNA, 1992
Address
are
than
(IL.).
1992; revision received March 6; accepted April 24. Supported in part by Domier Medical Systems. H.M. supported by Dornier Medical Systems and Sterling-Winthrop. BR. supported in part by Systems.
DNBLS
1. More
=
BL Dornier
=
biliary
National
lithotripsy, Biliary
Lithotripsy
735
Table 1 Patient Selection
Criteria
and
Protocol
Treatment
of Six Centers
Stone Study DNBLS
1-3 stones
Shock
Stones
Demographics
Treated
Used
each up to Yes,