Non-surgical treatment of gall stones: many contenders but who will win the crown?

Pharmacology of bile acids and their derivatives: Absorption promoters and therapeutic agents

The role of bile acids in pharmacotherapy is reviewed in this article. The therapeutic use of bile has been recognized since ancient times. Previously bile acids were the standard treatment for gallstones where chenodeoxycholic acid and ursodeoxycholic acid were effective in promoting the dissolution of cholesterol gallstones. Today their therapeutic role looks set to expand enormously. Bile acids as absorption promoters have the potential to aid intestinal, buccal, transdermal, ocular, nasal, rectal and pulmonary absorption of various drugs at concentrations that are non-toxic. Keto derivatives of cholic acid, such as 3a,7a,dihydroxy-12-keto-5alpha-cholic acid (sodium salt and methyl ester) are potential modifiers of blood-brain barrier transport and have been shown to promote quinine uptake, enhance the analgesic effect of morphine and prolong the sleeping time induced by pentobarbital. They have also been shown to be hypoglycaemic. Bile acids as therapeutic agents have the potential to produce beneficial effects in sexually transmitted diseases, primary biliary cirrhosis, primary sclerosing cholangitis, gallstones, digestive tract diseases, cystic fibrosis, cancer and diabetes.

Management of common bile duct stones using a second-generation extracorporeal shockwave lithotriptor

Fifty-four patients with common bile duct stones (8-36 mm in diameter) that could not be removed after endoscopic sphincterotomy, even with the use of mechanical lithotripsy, underwent extracorporeal shockwave lithotripsy (ESWL) using a Siemens Lithostar. Their median age was 75.5 (range 34-89) years. Patients received 4000-6000 shocks per session over approximately 60 min. Seventeen underwent two sessions and two patients three or more. Thirty-seven patients had one stone, ten had two, and seven had three or more. Spontaneous clearance of fragments occurred in only three patients before further endoscopic retrograde cholangiopancreatography was performed to remove fragments. Stones were removed and ducts cleared endoscopically in 35 patients, giving a total of 38 of 54 patients (70 per cent) with complete duct clearance. Fragmentation in response to lithotripsy was dependent on stone size; the number of stones had little effect. ESWL was well tolerated without any haematological or biochemical abnormality. Computed tomography in the first 20 patients showed no hepatic or pancreatic change after treatment. ESWL combined with endoscopic extraction of fragments is an alternative to surgery when preliminary endoscopic extraction and mechanical lithotripsy have failed.

Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results

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.

In vitro comparison of different gall stone dissolution solvents

Extracorporeal shockwave lithotripsy (ESWL) of gall bladder stones leaves residual fragments that need to be dissolved by chemical solvents. In this study we compared the in vitro dissolving capacity of methyl tert-butyl ether (MTBE), mono-octanoin, limonene, and limonene/mono-octanoin (70%/30%). From nine sets of five human gall stones obtained at cholecystectomy, four stones were used for dissolution and the fifth was used for chemical analysis of cholesterol, calcium, and bilirubin contents. Eight sets were cholesterol stones with a mean (SD) cholesterol content of 89.9 (5.6)%. These stones dissolved completely in either solvent, often leaving sand-like debris, with the exception of one stone. MTBE dissolved cholesterol gall stones 100 times faster than mono-octanoin and 10 times faster than limonene or the limonene/mono-octanoin mixture (p less than 0.001). The combination of limonene and mono-octanoin was as effective as limonene alone. Of the four solvents, MTBE is the best one to evaluate for dissolution of residual fragments after ESWL treatment of gall bladder stones.

Non-surgical options for the management of gallstone disease: an overview

The modalities for the non-surgical treatment of gallstones include oral dissolution by bile salts, local dissolution by methyl-tert-butyl-ether (MTBE), extracorporeal shockwave lithotripsy (ESWL) and percutaneous gallstone clearance. The results of oral bile salt therapy for cholesterol stones have been disappointing, and the only indication for this treatment is after ESWL. The high efficacy initially reported for MTBE has not been confirmed by subsequent experience in other centres: this therapy is toxic and best confined to specialized centres. ESWL, though effective in noncalcified stones, has limited overall applicability (approx. 15%) and is frequently followed by recurrence despite maintenance therapy with oral bile salts. Percutaneous gallstone clearance (radiologic or laparoscopic) has been superseded by laparoscopic cholecystectomy. This offers definitive treatment in a single session and has significant advantages over open cholecystectomy in terms of short hospital stay and accelerated recovery with early return to work or full activity. Destruction of the gallbladder by sclerosant agents (chemical cholecystectomy) requires further experimental evaluation before its introduction to clinical practice.

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Successful chemical cholecystectomy: a laparoscopic guided technique

A laparoscopic guided technique of percutaneous chemical destruction of the gall bladder is described. The procedure entails the creation of a percutaneous access cholecystostomy for stone removal/fragmentation. After endoscopic occlusion of the cystic duct, the alkali corrosive, sodium carbonate was instilled into the gall bladder for 10-15 minutes. The treatment was applied in 11 animals with three deaths because of technical mishaps and eight survivors, in five of which a histologically confirmed complete destruction of the gall bladder (chemical cholecystectomy) was achieved without damage to the rest of the biliary tract or liver parenchyma.

Endoscopic biliary therapy using the combined percutaneous and endoscopic technique

Between September 1985 and December 1987, 74 patients underwent attempted endoscopic biliary therapy using a combined percutaneous transhepatic and endoscopic transpapillary approach (combined procedure). All patients had had failed endoscopy-alone procedures and had contraindications to surgery. The indication was palliation of malignant biliary obstruction in 66 cases (41 common bile duct, 25 hilar), assistance with sphincterotomy for the removal of common bile duct stones in 6 cases, and management of benign biliary stenosis in 2 cases. The initial procedure was percutaneous transhepatic access to the biliary tree, which was successful in all but 1 case (99%). The bile duct was drained externally for an average of 3.4 days before the combined procedure. One patient died during this period from hemorrhage associated with liver puncture. Combined procedure was performed in 72 cases and was successful in 60 [53 malignant stricture (53/66 = 80%), five common duct stone (5/6 = 83%), two benign stricture (2/2 = 100%)]. Procedure-related morbidity and mortality, respectively, were 12.5% and 0% for benign disease and 36% and 3% for malignant disease. The total (initial endoscopy included) morbidity and 30-day mortality were 33% and 0%, respectively, for benign disease and 62% and 27% for malignant disease. Subsequently, stent change has been required on 16 occasions, with endoscopy-only successful in 13 (81%) and repeat combined procedure being required in three (19%). The combined procedure improves the ability of endoscopy to offer nonsurgical therapy to poor risk patients with both malignant and benign biliary disease but is associated with significant morbidity and disease-related mortality.