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Peron A, Schliemann AL, Almeida FAD. Understanding the reasons for the refusal of cholecystectomy in patients with cholelithiasis: how to help them in their decision? ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2015; 27:114-9. [PMID: 25004289 PMCID: PMC4678679 DOI: 10.1590/s0102-67202014000200007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 01/16/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cholelithiasis is prevalent surgical disease, with approximately 60,000 admissions per year in the Unified Health System in Brazil. Is often asymptomatic or oligosymptomatic and major complications arise from the migration of calculi to low biliary tract. Despite these complications are severe and life threatening, some patients refuse surgical treatment. AIM To understand why individuals with cholelithiasis refuse cholecystectomy before complications inherent to the presence of gallstones in the bile duct and pancreatitis occur. METHODS To investigate the universe of the justifications for refusing to submit to surgery it was performed individual interviews according to a predetermined script. In these interviews, was evaluate the knowledge of individuals about cholelithiasis and its complications and the reasons for the refusal of surgical treatment. Were interviewed 20 individuals with cholelithiasis who refused or postponed surgical treatment without a plausible reason. To these interviews, was applied the technique of thematic analysis (Minayo, 2006). RESULTS The majority of respondents had good knowledge of their disease and its possible complications, were well oriented and had surgical indications by their physicians. The refusal for surgery was justified primarily on negative experiences of themselves or family members with surgery, including anesthesia; fear of pain or losing their autonomy during surgery and postoperative period, preferring to take the risk and wait for complications to then solve them compulsorily. CONCLUSION The reasons for the refusal to surgical resolution of cholelithiasis were diverse, but closely related to personal (or related persons) negative surgical experiences or complex psychological problems that must be adequately addressed by the surgeon and other qualified professionals.
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Affiliation(s)
| | - Ana Laura Schliemann
- Faculdade de Psicologia, Pontifícia Universidade Católica de São Paulo, Sorocaba, SP, Brazil
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Mousavi SA, Karami H, Barzegarnejad A. The effect of extracorporeal shock wave lithotripsy in the management of idiopathic gallstones in children. J Indian Assoc Pediatr Surg 2014; 19:218-21. [PMID: 25336804 PMCID: PMC4204247 DOI: 10.4103/0971-9261.142010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Objective: The most common etiology for gallstones in children is hemolytic diseases; however, the prevalence of nonhemolytic gallstones, which are mostly idiopathic, is increasing. Several studies concerning the treatment of gallstones with respect to the influence of extracorporeal shock wave lithotripsy (ESWL) have been conducted in adults, but not to the same extent in children. Therefore, this study attempted to examine the effects of lithotripsy on idiopathic gallstones in children. Materials and Methods: In this study, 12 children, all of whom were under 12 years of age and diagnosed with idiopathic gallstones, were treated with ESWL. The average age of the children examined in this study was 6.5 years (range 3-11 years). Patients were treated with 2500-3000 shockwaves per session. The number of shockwaves was 90 shocks/min and the impulse intensity ranged from 10 to 12 kV. The final goal was the fragmentation of stones in pieces with less than 3 mm in dimension. Patients were followed up for 6-30 months. Results: A total of 12 patients were treated with ESWL for 14 rounds. In three patients, complete fragmentation occurred within the first trial and was cleared. The nine remaining patients underwent ESWL 10 times in which an acceptable change in the gallstone's condition was not observed. Five of the patients underwent surgery. The chemical composition of the gallstones showed that the dominant element in them was calcium. Conclusions: Our findings show that performing ESWL can be effective in some children. Further studies with larger population are recommended. Furthermore, it seems increasing the voltage intensity and frequency as conducted in adults accompanied with biliary acids prescription can be effective in children.
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Affiliation(s)
- Seyed Abdollah Mousavi
- Department of Pediatric Surgery, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hasan Karami
- Department of Pediatric Gastroenterology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ayub Barzegarnejad
- Department of Urology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
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3
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Abstract
BACKGROUND Successful extraction of common bile duct stones after endoscopic sphincterotomy may be achieved in 86-96 per cent of cases. However, some stones are too large to be removed in this manner. This study looks at the role of extracorporeal shock-wave lithotripsy to break up common bile duct stones as an adjunct to sphincterotomy in patients with stones greater than 10 mm in size. METHODS Twenty-seven patients with large (10-35 mm) common bile duct stones were treated with piezoelectric generated extracorporeal shock-wave lithotripsy (ESWL) following failed stone extraction after endoscopic sphincterotomy (ES). The stones were visualized ultrasonographically and a piezolith 2300 Wolf lithotripter used to administer the shockwaves. RESULTS Visualized stone fragmentation was reported in 20 of 48 sessions. Clearance of targeted stones was achieved in 18 of the 27 patients, but actual duct clearance was demonstrated in only 17 of the 27. There were few adverse effects and mortality was nil. CONCLUSION This study concludes that ESWL following failed ES is a useful additional treatment option for very large bile duct stones, but should only be used after surgical risk and past history of biliary disease have been carefully reviewed and found to contraindicate conventional surgical management. An algorithm of treatment options for common bile duct stones is presented.
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Gilchrist AM, Ross B, Thomas WEG. Extracorporeal shockwave lithotripsy for common bile duct stones. Br J Surg 1997. [DOI: 10.1002/bjs.1800840109] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Moreaux J. Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience. Am J Surg 1995; 169:220-6. [PMID: 7840384 DOI: 10.1016/s0002-9610(99)80141-x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE To analyze the operative findings and evaluate the hospital morbidity and mortality. This experience is documented in order to provide a basis for comparison with therapeutic alternatives. PATIENTS AND METHODS Prospective data were collected on 579 patients who underwent elective (n = 443) or emergent (n = 136) operations between 1970 and 1990. Their mean age was 60.1 years. Prior biliary symptoms were present in 96% and suggestive of choledocholithiasis in 69%. Acute pancreatitis was associated in 3%. RESULTS Cholecystectomy was performed with intraoperative cholangiography in 85% of cases. Stones were extracted via the cystic duct in 18%, through a choledochotomy in 79%, and through an additional sphincterotomy in 3%. Cholangioscopy has been routinely used since 1977. The incidence of extraction of the stones via the cystic duct increased and the incidence of biliary-enteric bypass decreased significantly during the second decade. Complications occurred in 24.5% of the patients. General complications were significantly fewer in the second decade than in the first (6% versus 15%). The main biliary complications were related to biliary tubes (5%) and retained stones (5%). Ten patients (2%) required early reoperation. The overall mortality rate was 0.3%. Mortality was 1.4% after emergency operations and zero after elective operations and in patients under 60 years of age. The mean stay was 16.6 +/- 7.2 days, decreasing with time. CONCLUSION Traditional open surgery is an effective and safe option for the management of cholelithiasis with choledocholithiasis. The choice between open surgery, laparoscopic surgery, and endoscopic sphincterotomy should be made for each patient according to the local availability and efficacy of these methods.
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Affiliation(s)
- J Moreaux
- Centre Médico-Chirurgical de la Porte de Choisy, Paris, France
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Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993; 218:129-37. [PMID: 8342992 PMCID: PMC1242921 DOI: 10.1097/00000658-199308000-00003] [Citation(s) in RCA: 280] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study evaluated, in a large, heterogeneous population, the outcome of open cholecystectomy as it is currently practiced. SUMMARY BACKGROUND AND DATA: Although cholecystectomy has been the gold standard of treatment for cholelithiasis for more than 100 years, it has recently been challenged by the introduction of several new modalities including laparoscopic cholecystectomy. Efforts to define the role of these alternative treatments have been hampered by the lack of contemporary data regarding open cholecystectomy. METHODS A population-based study was performed examining all open cholecystectomies performed by surgeons in an eastern and western state during a recent 12-month period. Data compiled consisted of a computerized analysis of Uniformed Billing (UB-82) discharge analysis information from all non-Veterans Administration (VA), acute care hospitals in California (Office of Statewide Planning and Development [OSHPD]) and in Maryland (Health Services Cost Review Commission [HSCRC]) between January 1, 1989, and December 31, 1989. This data base was supplemented with a 5% random sample of Medicare UB-82 data from patients who were discharged between October 1, 1988, and September 30, 1989. Patients undergoing cholecystectomy were identified based on diagnosis-related groups (DRG-197 and DRG-198), and then classified by Principal Diagnosis and divided into three clinically homogeneous subgroups: acute cholecystitis, chronic cholecystitis, and complicated cholecystitis. RESULTS A total of 42,474 patients were analyzed, which represents approximately 8% of all patients undergoing cholecystectomy in the United States in any recent 12-month period. The overall mortality rate was 0.17% and the incidence rate of bile duct injuries was approximately 0.2%. The mortality rate was 0.03% in patients younger than 65 years of age and 0.5% in those older than 65 years of age. Mortality rate, length of hospital stay, and charges were all significantly correlated (p < 0.001) with age, admission status (elective, urgent, or emergent), and disease status. CONCLUSIONS These data indicate that open cholecystectomy currently is a very safe, effective treatment for cholelithiasis and is being performed with near zero mortality. The ultimate role of laparoscopic cholecystectomy needs to be defined in the context of current and contemporary data regarding open cholecystectomy.
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Affiliation(s)
- J J Roslyn
- Department of Surgery, Medical College of Pennsylvania, Philadelphia
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Clavien PA, Sanabria JR, Mentha G, Borst F, Buhler L, Roche B, Cywes R, Tibshirani R, Rohner A, Strasberg SM. Recent results of elective open cholecystectomy in a North American and a European center. Comparison of complications and risk factors. Ann Surg 1992; 216:618-26. [PMID: 1466614 PMCID: PMC1242707 DOI: 10.1097/00000658-199212000-00002] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Results of elective open cholecystectomy in 1252 patients treated in a North American and a European center were examined using a recent standardized classification of complications. Although there were significant differences between centers in population age, rate of concomitant disorders, and numbers of operators, the frequency and severity of complications were comparable. There were no deaths, but 12% and 14% of the patients developed complications in the two centers. About 6% of the patients developed grade I complications. Grade II complications were noted in 6% and 8%, and grade III in 0% and 0.3%. Using univariate and multivariate analysis, individual risk factors for developing complications were found to be different in the two centers. Two preoperative scoring systems, ASA and a simplified APACHE II, were predictive for complications in both centers, but did not account for all risk in these patients. Data from the two centers could not be combined because of significant interaction between risk factors and center. Elective open cholecystectomy is a safe procedure, particularly in terms of highly morbid complications and death. Generalization of risk factors identified in a particular center may be misleading because local conditions may significantly affect risk factors for complications. The data also demonstrate the advantages of a uniform way of reporting surgical complications, which may permit meaningful comparisons among centers.
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Affiliation(s)
- P A Clavien
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Ertan A, Hernandez RE, Campeau RJ, Geshner JR, Litwin MS. Extracorporeal shock-wave lithotripsy and ursodiol versus ursodiol alone in the treatment of gallstones. Gastroenterology 1992; 103:311-6. [PMID: 1612339 DOI: 10.1016/0016-5085(92)91128-q] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- A Ertan
- Department of Radiology, Tulane University Medical Center, New Orleans, Louisiana
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Saunders-Kirkwood KD, Aizen B, Thompson JE, Zinner MJ, Cates JA, Bennion R, Gill J, Boudi F, Roslyn JJ. Cholecystectomy. The impact of socioeconomic change. Ann Surg 1992; 215:318-25. [PMID: 1558411 PMCID: PMC1242446 DOI: 10.1097/00000658-199204000-00003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The impact of our evolving health care system on a commonly performed surgical procedure, cholecystectomy, was assessed in a county-subsidized and private university hospital setting. Although condition on admission, use of resources, and outcome were unchanged in the private setting between 1980 and 1988, significant differences were noted among the largely uninsured patients at the county facility during this same time interval. There was a significant increase in the acuity of illness among patients undergoing cholecystectomy at the county hospital in 1988 as compared with 1980. These data suggest that alterations in reimbursement strategies and allocation of resources are significantly impacting on patient care, particularly in nonprivate health care facilities.
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11
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Erdamar I, Avci G, Füzün M, Harmancioğlu O. Extracorporeal shockwave lithotripsy and litholytic therapy in cholelithiasis. Br J Surg 1992; 79:235-6. [PMID: 1555089 DOI: 10.1002/bjs.1800790316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Extracorporeal shockwave lithotripsy (ESWL) and litholytic therapy were used in 100 patients over a period of 16 months. ESWL was carried out with a Lithostar Plus and chenodeoxycholic acid was used as the lytic agent, given until 3 months after complete disappearance of stones. Within a period of 8-12 months, stones disappeared completely in 82 per cent of the patients who had a single stone less than or equal to 20 mm in diameter and in 50 per cent of those with a single stone greater than 20 mm in size or with multiple stones. Complications requiring surgery developed in five patients: three had acute cholecystitis and two developed acute pancreatitis. Of the patients in whom complete stone clearance was achieved, two of 11 followed up developed recurrence of stones 4 months after cessation of lytic therapy.
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Affiliation(s)
- I Erdamar
- Department of Surgery, Dokuz Eylül University Medical School, Izmir, Turkey
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12
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Meiser G, Heinerman M, Lexer G, Boeckl O. Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results. Gut 1992; 33:277-81. [PMID: 1371761 PMCID: PMC1373945 DOI: 10.1136/gut.33.2.277] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Two hundred and twenty patients with a total of 412 gall bladder stones of between 8 and 38 mm in size were treated with extracorporeal shock wave lithotripsy, using the overhead module Lithostrar Plus. Fifty six per cent of stones were solitary (mean (SD) diameter 23 (5) mm) and 9.5% of the patients had more than three stones. Stones were successfully disintegrated in 218 patients (fragmentation size less than 5 mm in 80%, less than 10 mm in 19%). Some 65% of patients required one treatment and the rest two or three. A mean (SD) of 4100 (1800) shock waves with a pressure of 700 bar were applied. Twenty four to 48 hours after lithotripsy a transient but significant increase in serum transaminase activities (31%) and in bilirubin (29%), urinary amylase (27%), and blood leukocyte (62%) values was observed. In 29% of patients there was a transient microhaematuria, in 2% transient macrohaematuria, and in 25% painless petechiae of the skin. Ultrasound showed temporary gall bladder wall oedema in 13%, temporary distension of the gall bladder in 11%, and transient common bile duct distension in 8% after treatment. After discharge from hospital, 31% of patients complained of recurrent colic that responded to simple analgesics. Four to eight weeks after therapy, four patients developed biliary pancreatitis and 11 biliary obstruction that was managed by endoscopy. To date, 105 patients have been followed for over 12 months. Sixty one of these had a solitary stone, 17 had two, and 27 had three or more stones. A total of 59 patients, including 44 with a primary solitary stone, eight with two stones, and seven with three or more stones are completely stone free.
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Affiliation(s)
- G Meiser
- 1st Surgical Department, Landeskrankenanstalten, Salzburg, Austria
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13
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Fendrick AM, de Pouvourville G, Bitker C, Pelletier G. Treatment of symptomatic cholelithiasis in France. A decision analysis comparing cholecystectomy and biliary lithotripsy. Int J Technol Assess Health Care 1992; 8:166-84. [PMID: 1601586 DOI: 10.1017/s0266462300008023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To determine the potential role of extracorporeal shock wave lithotripsy (ESWL) in the treatment of symptomatic gallstone patients in France, a simulation model evaluated the health and economic effects of three different treatment strategies. Decision analysis of conventional cholecystectomy alone and either of two strategies using a combination of biliary lithotripsy and conventional cholecystectomy reveals that a strategy employing biliary ESWL results in a significant number of successfully treated patients, thus avoiding the risks and costs of abdominal surgery. Moreover, cost analysis shows that expanding the use of lithotripsy to all patients for whom the procedure is indicated increases the average cost per successfully treated patient, but, more importantly, decreases the overall costs incurred by the cohort. From a societal viewpoint, a policy using biliary ESWL in appropriate patients is superior to one of cholecystectomy alone, from both clinical and economic perspectives.
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Affiliation(s)
- A M Fendrick
- Ecole Polytechnique and Assistance, Publique-Hôpitaux de Paris
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14
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Chung SC, Leung JW, Leong HT, Li AK. Mechanical lithotripsy of large common bile duct stones using a basket. Br J Surg 1991; 78:1448-50. [PMID: 1773322 DOI: 10.1002/bjs.1800781214] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Experience with the Olympus basket mechanical lithotriptor (BML-1Q) in crushing large common bile duct stones before their endoscopic removal is reported. From January 1988 to January 1990, 68 patients with common duct stones too large to be extracted by Dormia baskets or balloon catheters after sphincterotomy were treated with the BML system. The largest stones in each patient ranged from 1.0 to 4.9 cm in diameter. Fifty-seven patients required one session of lithotripsy, ten patients two sessions and one patient three sessions; 26 patients required further endoscopic extraction of stone fragments after successful lithotripsy. The stones were successfully crushed by the BML system and the ducts cleared in 55 patients (81 per cent). In 13 patients mechanical lithotripsy failed because the stones could not be engaged in the lithotriptor basket. In one patient the stone was crushed with the Soehendra lithotriptor, six patients were successfully managed by electrohydraulic lithotripsy through a 'mother and baby' endoscope, indwelling stents were inserted in four patients and two patients underwent surgery.
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Affiliation(s)
- S C Chung
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin
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Saunders KD, Cates JA, Abedin MZ, Rege S, Festekdjian SF, Howard W, Roslyn JJ. Lovastatin inhibits gallstone formation in the cholesterol-fed prairie dog. Ann Surg 1991; 214:149-54. [PMID: 1867522 PMCID: PMC1358514 DOI: 10.1097/00000658-199108000-00009] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The efficacy of lovastatin, an inhibitor of hepatic cholesterol synthesis in the prevention of cholesterol gallstone formation, was evaluated in the prairie dog model. Two groups of animals were maintained on either nonlithogenic or 1.2% cholesterol-enriched chow for 21 days. Seven of the animals in each group received lovastatin, and the remaining six received only distilled water. All of the cholesterol-fed/water-treated animals had crystals and 83% had gallstones, but none of the cholesterol-fed/lovastatin-treated animals had gallstones and only three had microscopic crystals. These data indicate that lovastatin inhibits cholesterol gallstone formation in a diet-induced model of gallstone disease.
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Affiliation(s)
- K D Saunders
- Research and Surgical Services, Sepulveda Veterans Administration Medical Center, California
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Affiliation(s)
- S M Strasberg
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
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Bass EB, Steinberg EP, Pitt HA, Saba GP, Lillemoe KD, Kafonek DR, Gadacz TR, Gordon TA, Anderson GF. Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones. Gastroenterology 1991; 101:189-99. [PMID: 1904378 DOI: 10.1016/0016-5085(91)90477-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To evaluate the cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy for symptomatic gallstones, a model was constructed that projects charges and survival for both treatments. For a 45-year-old woman with one small stone, treatment with extracorporeal shock-wave lithotripsy rather than cholecystectomy is projected to result in an average gain of only 3 days of life and an average increase in direct medical charges of $1729 over 5 years of follow-up. The resulting marginal cost-effectiveness of extracorporeal shock-wave lithotripsy vs. cholecystectomy is $216,000 of extra charges per year of life gained with extracorporeal shock-wave lithotripsy. Extracorporeal shock-wave lithotripsy is projected to be much more cost-effective for elderly than for young patients (10-20-fold difference), but considerably less cost-effective for multiple stones than a single stone (2-4-fold difference), and less cost-effective for women than men (twofold difference). Adjusting for effects of morbidity on quality of life, extracorporeal shock-wave lithotripsy is projected to have slightly better quality-adjusted survival than cholecystectomy for the small subset of patients with one stone (by 8 to 43 days at 5 years) but not for young patients with multiple stones. It is concluded that decisions about appropriate use of extracorporeal shock-wave lithotripsy should consider the effects of patient characteristics on clinical and economic outcomes.
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Affiliation(s)
- E B Bass
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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18
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Nealon WH, Urrutia F, Fleming D, Thompson JC. The economic burden of gallstone lithotripsy. Will cost determine its fate? Ann Surg 1991; 213:645-9; discussion 649-50. [PMID: 2039296 PMCID: PMC1358595 DOI: 10.1097/00000658-199106000-00015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gallstone lithotripsy (LITHO) was performed on 52 patients who underwent 107 procedures. Two hundred sixty-seven gallstone patients were screened and 215 (81%) were excluded. Excessive stone burden and nonvisualization by oral cholecystogram (OCG) were the most common reasons for exclusion. The hospital course of 100 excluded patients who later underwent elective cholecystectomy was evaluated for length of hospital stay (2.3 days) and total cost of treatment ($3685.00). Successful fragmentation to less than 5 mm was achieved in 43 LITHO patients (83%). Five LITHO patients (10%) required conversion to operative management. Complications of LITHO included acute cholecystitis (1 of 52 patients) and biliary colic (17 of 52 patients, or 33%). Multiple procedures in one patient were common. Costs for LITHO were calculated in two ways: first the individual cost for each of the 52 candidates; second the cost for successful LITHO was calculated by excluding five patients who required operation as well as five patients (10%) who are predicted failures of LITHO. Including the preoperative evaluation, treatment, recovery room, and follow-up, the individual LITHO cost for 52 patients was $8275.00. If the same total expenditure is calculated after excluding patients who required operation and those predicted to fail, the cost per 'successful' LITHO procedure was $10,245. The cost of 1 year of bile acid therapy is $1949.00 or $2413.00 per 'successful' procedure. Follow-up costs were $1232.00 per patient or $1525.00 per 'successful' procedure. The added LITHO cost incurred by screening eventual noncandidates was $904.00 per successful procedure. The sum of these individual costs was $15,087.00 per success, as compared to $3685.00 for cholecystectomy. No allowance was made for cost of stone recurrence. Lithotripsy costs appear to be sufficiently high to render the procedure unlikely to emerge as the treatment of choice.
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Affiliation(s)
- W H Nealon
- Department of Surgery, University of Texas Medical Branch, Galveston 77550
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19
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Darzi A, Keane FB. Gallbladder surgery following cholecystlithotripsy: suggested guidelines for treatment. Br J Surg 1991; 78:506-7. [PMID: 2032121 DOI: 10.1002/bjs.1800780445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Many new therapies for the management of gallstone disease have been pioneered in the past decade. The object of this review is to equip the surgeon with the answers to all of the questions a patient will ask about gallstone therapy; the review is therefore didactic as well as comprehensive.
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21
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Lee SH, Burhenne HJ. Gallbladder surgery following cholecystlithotripsy: suggested guidelines for treatment. Br J Surg 1990; 77:1268-71. [PMID: 2253007 DOI: 10.1002/bjs.1800771122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Twenty-three of 229 symptomatic patients undergoing cholecystlithotripsy underwent surgical intervention: 22 of the patients had cholecystectomy performed (five also undergoing choledochotomy) and one patient had a cholecystostomy. Of these 23 patients, five were lithotripsy failures, five developed acute pancreatitis, one had acute cholecystitis, and one had cholangitis. One patient had her gallbladder removed incidentally at the time of surgery for a bleeding gastric ulcer. Ten patients underwent surgery for recurrent biliary pain, probably related to fragment passage via the cystic duct. We suggest that up to 16 of these 23 patients did not necessarily require cholecystectomy, i.e. five patients with pancreatitis, one patient with cholangitis and ten patients with recurrent biliary colic. Conservative and/or endoscopic management may be successful in the first instance to allow further treatment with lithotripsy in the majority of patients. If, however, the expertise to perform endoscopic sphincterotomy is not available or the patient declines further lithotripsy, then resort to surgery may be necessary. We propose that it is the responsibility of the management team in charge of the lithotripsy unit to inform both the patient and the referring clinicians of the possible side-effects and outcome of treatment in an attempt to avoid unnecessary surgical procedures.
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Affiliation(s)
- S H Lee
- Department of Radiology, University of British Columbia, Vancouver, Canada
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22
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Griffith DP, Rubio PA, Gleeson MJ. Percutaneous endoscopic treatment of cholelithiasis. Surg Endosc 1990; 4:141-8; discussion 149. [PMID: 2148445 DOI: 10.1007/bf02336592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Surgical management of gallstones was first performed successfully in 1878. Over the past decade, several new treatment alternatives have evolved that challenge the supremacy of traditional surgical cholecystectomy. Two endoscopic alternatives, e.g., percutaneous cholecystolithotomy (PCCL) and laparoscopic cholecystectomy (LC) are the latest additions to the growing armamentarium. Our initial experience with PCCL and LC as compared with our traditional cholecystectomy experience shows a 57% reduction in hospital days, a 58% reduction in postoperative analgesic dose, and 50% or more reduction in disabling convalescence in favor of the endoscopic alternatives. A review of the efficacy and morbidity of traditional surgery, peroral drug chemolysis (PDC), shockwave lithotripsy plus PDC, and percutaneous transhepatic lavage with methyl terbutyl ether suggests that the endoscopic alternatives are less morbid than traditional surgery and more efficacious and perhaps less morbid than other non-invasive or minimally invasive alternatives. Both original data and a literature review are presented.
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Affiliation(s)
- D P Griffith
- Department of Endoscopic Surgery, Baylor College of Medicine, Houston, TX 77030
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23
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Peel AL. The challenge of the bile duct in 1990. Ann R Coll Surg Engl 1990; 72:165-7. [PMID: 2192674 PMCID: PMC2499177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- A L Peel
- North Tees District General Hospital, Hardwick, Stockton-on-Tees, Cleveland
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24
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Vergunst H, Terpstra OT, Brakel K, Laméris JS, van Blankenstein M, Schröder FH. Extracorporeal shockwave lithotripsy of gallstones. Possibilities and limitations. Ann Surg 1989; 210:565-75. [PMID: 2684058 PMCID: PMC1357788 DOI: 10.1097/00000658-198911000-00001] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Recently extracorporeal shockwave lithotripsy (ESWL) has been introduced as a nonoperative treatment for gallstone disease. Except for lung damage, no significant adverse effects of ESWL of gallbladder stones have been observed in animals. In clinical use ESWL of gallbladder stones is now confined to 15% to 30% of symptomatic patients. To achieve complete stone clearance, ESWL of gallbladder stones must be supplemented by an adjuvant therapy. ESWL of bile duct stones is highly effective and can be considered in patients in whom primary endoscopic or surgical stone removal fails. Second generation lithotriptors allow anesthesia-free (outpatient) treatments, but the clinical experience with most of these ESWL devices is still limited. The likelihood of gallbladder stone recurrence is a major disadvantage of ESWL treatment, which raises the issue of cost-effectiveness. ESWL for cholelithiasis is a promising treatment modality with good short-term and unknown long-term results.
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Affiliation(s)
- H Vergunst
- Department of Surgery, University Hospital Dijkzigt, Rotterdam, The Netherlands
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25
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Marberger M, Hruby W, Stackl W, Armbruster C. Percutaneous cholecystolithotripsy: Lessons learned. World J Urol 1989. [DOI: 10.1007/bf01637366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Abstract
Extracorporeal shock-wave lithotripsy (ESWL) in combination with adjuvant litholytic therapy using chenodeoxycholic acid and ursodeoxycholic acid (7 to 8 mg/kg body weight/day of each acid) is a safe and effective, novel nonsurgical approach to gallbladder stones, provided the patients are carefully selected. Experience has shown that patients with a radiolucent solitary stone in a functioning gallbladder are the best candidates. In addition, ESWL is a worthwhile noninvasive alternative to open surgery in patients with bile duct stones in whom routine endoscopic measures have failed.
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Affiliation(s)
- T Sauerbruch
- Medical Department II, Klinikum Grosshadern, University of Munich, Federal Republic of Germany
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27
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Malt RA, Rothschild JG, Holbrook RF, Mueller PR, Simeone JF, Latta WB, Kimball WR, Reinhold RB. Extracorporeal shock-wave lithotripsy of gallstones: Boston experience with the Dornier MPL 9000 lithotripter. Am J Surg 1989; 158:192-3. [PMID: 2774067 DOI: 10.1016/0002-9610(89)90250-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
After the success of shock-wave therapy for fragmentation of renal stones, machines for shock-wave therapy of gallbladder stones were quick to follow. In Munich, gallstones were successfully treated in 174 of 175 patients who were also taking ursodiol to help solubilize the calculous rubble left after treatment. In Boston, of the initial 87 patients accepted, 58 were treated for a single stone (mean diameter 15.7 mm), 16 were treated for 2 stones, and 13 for 3 stones. Although reporting of exact results is not possible before the Food and Drug Administration issues a clearance, it is fair to say that both patients and physicians are generally pleased with the results.
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Affiliation(s)
- R A Malt
- Surgical Services, Massachusetts General Hospital, Boston 02114
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28
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Abstract
The new nonsurgical methods of treating gallstone disease rely on fragmentation, such as with extracorporeal shock-wave lithotripsy (ESWL), or dissolution, such as with ursodiol. Fragmentation alone is usually insufficient for gallbladder stones, and dissolution is only possible for cholesterol stones. Although oral dissolution with or without ESWL is an attractive alternative to surgery, only 25 percent of patients are candidates for this therapy. Dissolution of gallbladder stones by topical application of methyl tert-butyl ether (MTBE) is another option whose safety is still open to question. Therefore, cholecystectomy will remain the principal treatment for symptomatic gallbladder stones. Common duct stones can be eliminated in 90 percent of cases by endoscopic sphincterotomy alone, and fragmentation of large common duct stones by mechanical endoscopic lithotripsy or ESWL can bring the success rate up to about 95 percent. Unless cholecystectomy is also required, surgery will have a secondary role in the treatment of common duct stones.
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Affiliation(s)
- L W Way
- Surgical Service, Veterans Affairs Medical Center, San Francisco, California 94121
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29
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Ertan A, Hernandez RE, Schade RR, Van Thiel DH. Who should conduct extracorporeal shock-wave biliary lithotripsy studies? Dig Dis Sci 1989; 34:996-8. [PMID: 2743852 DOI: 10.1007/bf01536362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- A Ertan
- Division of Gastroenterology, Tulane University Medical School, New Orleans, Louisiana 70112
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30
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Reddick EJ, Olsen DO, Daniell JF, Saye WB, McKernan B, Miller W, Hoback M. Laparoscopic Laser Cholecystectomy. ACTA ACUST UNITED AC 1989. [DOI: 10.1089/lms.1989.7.1.38] [Citation(s) in RCA: 84] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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31
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Reddick EJ, Olsen DO. Laparoscopic laser cholecystectomy. A comparison with mini-lap cholecystectomy. Surg Endosc 1989; 3:131-3. [PMID: 2530643 DOI: 10.1007/bf00591357] [Citation(s) in RCA: 597] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The standard treatment of cholelithiasis in the United States is surgical removal of the gallbladder, but this treatment often has a major economic impact on the patient: major surgery, lengthy hospitalization, and several weeks' absence from work. Because of this economic factor, there has been a movement toward non-invasive methods, but they, too, have their drawbacks: long-term medical therapy; a high risk of stone recurrence because the diseased gallbladder is still in place. We therefore developed a means of performing a cholecystectomy through a laparoscope using laser technology, the results of which are compared here with the results in a series of "mini-lap" cholecystectomies that we also performed during the same time period.
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Affiliation(s)
- E J Reddick
- HCA Center for Research and Education, Nashville, TN 37203
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