Extracorporeal shock-wave lithotripsy for retained common bile duct stones

TOTAL OXIDANT AND ANTIOXIDANT LEVELS IN PATIENTS WITH GALLBLADDER STONES OR RELATED COMPLICATIONS: ARE THEY IMPORTANT FOR TREATMENT?

BACKGROUND

Many free radicals result in an inflammatory process due to complications caused by gallstones. These free radicals are inactivated by various reactions and participate in different reactions. Molecules are oxidants and antioxidants that take an active role in almost every event that takes place in the body.

AIMS

To analyse the changes in total antioxidant level (TAL) and total oxidant level (TOL) in the follow-up of patients hospitalized for cholelithiasis or its complications, showing the active oxidative stress, and to test the usability of these parameters in the evaluation of treatment success.

METHODS

Forty-five patients took part in the study. Blood samples were taken twice, previous to surgery and 6 hours after surgery. Tissue samples were also obtained from patients who were operated. Then, the samples were sent to a laboratory to measure the total oxidant and antioxidant status of patients.

RESULTS

The median for the TAL_before (pre-operation or hospitalization in non-operational) variable was 2.40 (interquartile range - IQR=0.50), and the median for the TAL_after variable was 2.20 (IQR=0.33). The median of the tissue-derived TAL variable was 0.32 (IQR=0.13), and the median of the TOL variable was 0.43 (IQR=0.52). The median value of the TAL_before variable for men was 2.50 (IQR=0.50), while the median value for the TAL_before variable for women was 2.30 (IQR=0.50). TAL_before variable values did not show a statistically significant difference according to gender (Z=1.446; p=0.154, p>0.05). Similarly, the median values of TOL_before variable by gender were similar (Z=0.614; p=0.545, p>0.05).

CONCLUSIONS

Cholelithiasis and its complications cause many inflammatory responses, ending with free radical formation. During follow-up, its level decreases due to consumption or success of the treatment.

Outcome of a session of extracorporeal shock wave lithotripsy before endoscopic retrograde cholangiopancreatography for problematic and large common bile duct stones

AIM

To compare the efficacy of a session of extracorporeal shock wave lithotripsy (ESWL) before endoscopic retrograde cholangiopancreatography (ERCP) vs ERCP only for problematic and large common bile duct (CBD) stones.

METHODS

Adult patients with CBD stones for whom initial ERCP was unsuccessful because of the large size of CBD stones were identified. The patients were randomized into two groups, an “ESWL + ERCP group” and an “ERCP-only” group. For ESWL + ERCP cases, ESWL was performed prior to ERCP. Clearance of the CBD, complications related to the ESWL/ERCP procedure, frequency of mechanical lithotripsy use and duration of the ERCP procedure were evaluated in both groups.

RESULTS

There was no significant difference in baseline characteristics between the two groups. A session of ESWL before ERCP compared with ERCP only resulted in similar outcomes in terms of successful stone removal within the first treatment session (74.2% vs 71.0%, P = 0.135), but a higher clearance rate within the second treatment session (84.4% vs 51.6%, P = 0.018) and total stone clearance (96.0% vs 86.0%, P = 0.029). Moreover, ESWL prior to ERCP not only reduced ERCP procedure time (43 ± 21 min vs 59 ± 28 min, P = 0.034) and the rate of mechanical lithotripsy use (20% vs 30%, P = 0.025), but also raised the clearance rate of extremely large stones (80.0% vs 40.0%, P = 0.016). Post-ERCP complications were similar for the two groups.

CONCLUSION

Based on the higher rate of successful stone removal and minimal complications, ESWL prior to ERCP appears to be a safe and effective treatment for the endoscopic removal of problematic and large CBD stones.

Using cholecystokinin to facilitate endoscopic clearance of large common bile duct stones

AIM: To evaluate the effect of cholecystokinin (CCK) during extracorporeal shockwave lithotripsy (ESWL) in the clearance of common bile duct (CBD) stones in endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: Between January 2007 and September 2012, patients with large CBD stones who were treated with ESWL and ERCP were identified retrospectively. Patients were randomized in equal numbers to cholecystokinin (CCK) and no CCK groups. For each CCK case, a dose (3 ng/kg per min for 10 min) of sulfated octapeptide of CCK-8 was administered intravenously near the beginning of ESWL. ERCP was performed 4 h after a session of ESWL. The clearance rate of the CBD was assessed between the two groups.

RESULTS: A total of 148 consecutive cases (CCK group: 74, no CCK group: 74) were tallied. Overall there were 234 ESWLs and 228 ERCPs in the 148 cases. The use of CCK showed a significantly higher rate of successful stone removal in the first ESWL/ERCP procedure (71.6% vs 55.4%, P = 0.035), but resulted in similar outcomes in the second (42.8% vs 39.4%) and third (41.7% vs 40.0%) sessions, as well as total stone clearance (90.5% vs 83.8%). The use of mechanical lithotripsy was reduced in the CCK group (6.8% vs 17.6%, P = 0.023), and extremely large stone (≥ 30 mm) removal was higher in the CCK group (72.7% vs 41.7%, P = 0.038).

CONCLUSION: CCK during ESWL can aid with the clearance of CBD stones in the first ESWL/ERCP session. Mechanical lithotripsy usage was reduced and the extremely large stone (≥ 30 mm) clearance rate can be raised.

Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: efficacy and analysis of factors that favor stone fragmentation

BACKGROUND AND AIM

Difficult common bile duct stones (CBD) are those not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon. The role of extracorporeal shock wave lithotripsy (ESWL) in stone fragmentation and clearance of difficult CBD stones and the factors which favor fragmentation were prospectively evaluated in the present study.

METHODS

A total of 283 patients with large CBD stones were subjected to ESWL. A maximum of 5000 shocks was delivered per session until CBD stones were fragmented to less than 5 mm diameter. CBD was cleared by biliary endotherapy using a basket or balloon. Outcome was assessed by CBD clearance.

RESULTS

Total CBD clearance was achieved in 239 patients (84.4%) and partial CBD clearance in 35 patients (12.3%). Three or fewer sessions of ESWL were required in 74.6% of patients. Minor complications were seen in 45 patients (15.9%). There was no procedure-related mortality. Epidural anesthesia, shock frequency of 90/min, radiolucent calculi and presence of fluid around the calculus helped in better fragmentation.

CONCLUSION

A high success rate, negligible complications and non-invasive nature of the procedure make ESWL a useful tool for removing large CBD stones.