Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Evaluation of sensitivity and inter- and intra-observer variability in the detection of intestinal metaplasia and dysplasia in Barrett's esophagus with enhanced magnification endoscopy

OBJECTIVE

Magnification endoscopy with acetic acid or dye for diagnosis of Barrett's esophagus is presently undergoing clinical evaluation. Current studies report good accuracy in predicting specialized intestinal metaplasia. To date, however, there is no definitive information on the inter- and intra-observer variability of these methods applied to the diagnosis of normal and dysplastic Barrett's mucosa.

MATERIAL AND METHODS

Sixty patients with endoscopically suspected Barrett's esophagus were investigated prospectively with the zoom endoscope after contrast enhancement of the mucosa with 1.5% acetic acid. Two hundred and twenty-three enlarged and histologically investigated areas of gastric, cardiac, normal and dysplastic Barrett's mucosa were photodocumented and in randomized sequence presented to 4 endoscopists in a blinded manner (2 with and 2 without experience of zoom endoscopy for evaluation). The reference for the first evaluation (A1) was standard endoscopic photographs of the respective, histologically confirmed mucosal entity. In a second evaluation (A2), the pictures were again interpreted by the same blinded investigators, but this time a modified pit-pattern classification as proposed by Sharma et al. was employed as the evaluation reference.

RESULTS

The diagnostic sensitivity for specialized intestinal metaplasia and dysplasia in Barrett's esophagus calculated for the A1 evaluation ranged -- investigator dependently -- from 54.9% to 80.7% and for A2 from 42.2% to 81.5%. The inter- and intra-observer variability for the evaluation procedure A1 and A2 was high (all kappa values <0.4). In particular, the inexperienced investigators demonstrated high intra-observer variability and low sensitivity in comparison with the experienced investigators.

CONCLUSIONS

The diagnosis of Barrett's mucosa using enhanced magnification endoscopy after acetic acid instillation is associated with a high level of interobserver variability. One reason is a frequent mismatch between cardiac mucosa and non-dysplastic Barrett's mucosa.

Sclerosing cholangitis following severe trauma: Description of a remarkable disease entity with emphasis on possible pathophysiologic mechanisms

AIM: Persistent cholestasis is a rare complication of severe trauma or infections. Little is known about the possible pathomechanisms and the clinical course.

METHODS: Secondary sclerosing cholangitis was diagnosed in five patients with persistent jaundice after severe trauma (one burn injury, three accidents, one power current injury). Medical charts were retrospectively reviewed with regard to possible trigger mechanisms for cholestasis, and the clinical course was recorded.

RESULTS: Diagnosis of secondary sclerosing cholangitis was based in all patients on the primary sclerosing cholangitis (PSC)-like destruction of the intrahepatic bile ducts at cholangiography after exclusion of PSC. In four patients, arterial hypotension with subsequent ischemia may have caused the bile duct damage, whereas in the case of power current injury direct thermal damage was assumed to be the trigger mechanism. The course of secondary liver fibrosis was rapidly progressive and proceeded to liver cirrhosis in all four patients with a follow-up >2 years. Therapeutic possibilities were limited.

CONCLUSION: Posttraumatic sclerosing cholangitis is a rare but rapidly progressive disease, probably caused by ischemia of the intrahepatic bile ducts via the peribiliary capillary plexus due to arterial hypotension. Gastroenterologists should be aware of this disease in patients with persistent cholestasis after severe trauma.

[A case of attenuated familial adenomatous polyposis coli (AFAP)]

We describe an asymptomatic female patient who was diagnosed with multiple tubular and tubulovillous adenomas in the right-sided colon on routine colonoscopy at the age of 59 years. Genetic testing identified a germline truncating mutation at codon 405 (R405X) of the adenomatous polyposis coli (APC) gene. This mutation is located in the alternatively spliced region of exon 9, a region that is associated with an attenuated phenotype of familial adenomatous polyposis (AFAP). To our knowledge this report describes for the first time the R405X germline mutation in association with AFAP. Our patient had no extracolonic manifestations of AFAP. Treatment consisted of a right hemicolectomy with ileotransversal anastomosis plus complete endoscopic polypectomy in the left-sided colon. AFAP is a poorly defined condition with unknown prevalence and penetrance that requires individual therapy and life-long surveillance. Because of marked intrafamilial phenotypic variance, it is crucial to identify these patients and implement proper endoscopic surveillance at an early age in family members carrying this mutation.

Ten years experience with piezoelectric extracorporeal shockwave lithotripsy of gallbladder stones

BACKGROUND

A critical review of the experience with extracorporeal shockwave lithotripsy (ESWL) of gallbladder stones is needed to clarify whether this method should continue to be applied to patients.

METHODS

Patients with symptomatic gallbladder stones were treated by piezoelectric ESWL according to a prospective protocol between 1988 and 1997. ESWL treatment was limited to a maximum of three (solitary stones <20 mm diameter) to five sessions (larger solitary or multiple stones) and 3000 pulses per session. Univariate and multivariate analyses of pretreatment and treatment variables were performed to investigate their impact on fragmentation efficacy and stone clearance. A tree-based analysis was used to identify prognostically homogenous subgroups of individuals with maximum benefit from ESWL.

RESULTS

Four hundred and eight patients, 76% female and 24% male, with a mean age of 46 (SD, 13) years, were selected for evaluation. Cox regression analysis identified three pretreatment variables with significant prognostic impact: (1) number of gallstones >1 (relative risk, 2.6 (95% CI, 1.9-3.5)), (2) size of stones >17 mm (1.7 (1.4-2.2)), and (3) computed tomography (CT) density of stones >55 Hounsfield units (H) (1.4 (1.1-1.8)). According to tree-based analysis, the stone clearance rate after 1 year was 85% (95% CI, 75-91%) for solitary stones <16 mm, 79% (70-86%) for solitary stones > or =16 mm with a CT density <84 H, 45% (32-55%) for solitary stones > or =16 mm with a CT density > or =84 H, and 42% (30-51%) for multiple stones. Five years after stone clearance, recurrence occurred in 43% of patients (95% CI, 39-47%).

CONCLUSIONS

ESWL treatment showed an acceptable stone clearance in the case of small solitary gallbladder stones (<16 mm) or larger solitary stones with a CT density <84 H, but a very low success rate in the case of multiple stones. The poor long-term success, however, is an important argument against the use of ESWL of gallbladder stones.

Extracorporeal shockwave lithotripsy of gallstones in cystic duct remnants and Mirizzi syndrome

BACKGROUND

Although the efficacy of extracorporeal shockwave lithotripsy for treatment of bile duct calculi is established, there are few studies of the value of extracorporeal shockwave lithotripsy for cystic duct remnant stones and for Mirizzi syndrome.

METHODS

Patients who required extracorporeal shockwave lithotripsy for cystic duct stones were identified in a cohort of 239 patients with bile duct stones treated by extracorporeal shockwave lithotripsy between January 1989 and December 2001 at a single institution. The medical records of these patients were reviewed. Follow-up information was obtained by telephone contact.

OBSERVATIONS

Six women (age range 19-85 years) underwent extracorporeal shockwave lithotripsy for cystic duct stones after failure of endoscopic treatment measures. Three of the patients presented with retained cystic duct remnant calculi (one also had Mirizzi syndrome type I), and 3 presented with Mirizzi syndrome type I. The stones were fragmented successfully by extracorporeal shockwave lithotripsy in all patients; the fragments were extracted endoscopically in 5 patients. Endoscopy plus extracorporeal shockwave lithotripsy was definitive treatment for all patients except one who subsequently underwent cholecystectomy.

CONCLUSIONS

Gallstones in a cystic duct remnant and in Mirizzi syndrome can be successfully treated by extracorporeal shockwave lithotripsy in conjunction with endoscopic measures. Extracorporeal shockwave lithotripsy is especially useful when surgery is contraindicated.

[Recurrent bouts of fever accompanied by abdominal pain and emesis]

A 34 year-old Turkish patient was admitted to hospital several times with the same symptoms of abdominal pain, fever up to 39.2 degrees C and vomiting. The diagnosis always was an acute attack of chronic pancreatitis. The inflammation scores in the blood were high and he had a moderate increase in pancreatic enzymes. He always got well in a few days on a strict diet and regime of analgesics. Taking these symptoms and his ethnic affiliation into consideration, differential diagnosis should include familial Mediterranean fever (FMF). Therapy with colchicine should be initiated even if genetic testing does not reveal the mutation characteristics for FMF. Immediate and consistent therapy helps to avoid amyloid nephropathy as the most dangerous complication of this disease.

Complete remission with long-term survival in a patient with esophageal carcinoma and a tracheoesophageal fistula after treatment with the AIO regimen and bi-weekly cisplatin

INTRODUCTION

To date, only few reports are available on patients with esophageal carcinoma containing a tracheoesophageal fistula under chemotherapy.

CASE REPORT

A 56-year-old patient presented to the hospital with a stenosing squamous cell carcinoma of the esophagus containing a tracheoesophageal fistula 3 cm above the carina. After placement of a Port-a-Cath and adequate hydration he received weekly 500 mg/m (2) i. v. folinic acid (FA) as a 1 - 2-hour infusion and 2000 mg/m (2) 5-fluorouracil (5-FU) as a 24-hour infusion (24-h inf.) (AIO regimen) with prior application of bi-weekly 50 mg/m (2) i. v. cisplatin. A tracheal Y-Dumont metallic stent was inserted prior to initiating systemic treatment. The patient's alimentation was completely parenteral. After three cycles of chemotherapy (six months) the patient revealed complete remission (CR) with closure of the tracheoesophageal fistula. The tracheal Y-Dumont stent could be removed and the patient had oral alimentation restored. 29 months after initiating treatment he is without evidence of disease.

CONCLUSION

Patients with esophageal carcinoma containing a tracheoesophageal fistula might benefit from chemotherapy and should not be generally excluded from systemic treatment.

Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success

BACKGROUND

The aim of the study was to evaluate interventional endoscopic management of pancreatic duct stones in patients with chronic pancreatitis by describing therapeutic methods and defining factors that predict technical success.

METHODS

Records were retrospectively analyzed for 125 patients with symptoms caused by chronic pancreatitis with pancreatic duct stones (single 43, multiple 82) treated by interventional endoscopy, including extracorporeal shockwave lithotripsy.

RESULTS

Technical success was achieved in 85% of patients (11 patients by mechanical lithotripsy, 114 by piezoelectric extracorporeal shockwave lithotripsy). There were no serious complications from lithotripsy. Univariate analysis disclosed a statistically significant association between treatment success and patient age as well as prepapillary location of stones. A greater therapeutic effort was necessary in patients with stones located in the tail of the pancreas, 2 or more stones, a stone 12 mm or more in diameter, or who have had a longer duration (>8 years) of the disease. However, with exception of the last parameter, correction for multiple testing of data removed statistical significance.

CONCLUSIONS

Extracorporeal shockwave lithotripsy enhances endoscopic measures for treatment of pancreatic duct stones when mechanical lithotripsy fails. Middle-aged patients in the early stages of chronic pancreatitis with stones in a prepapillary location proved to be the best candidates for successful treatment. Unfavorable patient-related or morphologic factors can be compensated for through more intense efforts at therapy.

Pancreatic duct stones in chronic pancreatitis: criteria for treatment intensity and success

BACKGROUND

The aim of the study was to evaluate interventional endoscopic management of pancreatic duct stones in patients with chronic pancreatitis by describing therapeutic methods and defining factors that predict technical success.

METHODS

Records were retrospectively analyzed for 125 patients with symptoms caused by chronic pancreatitis with pancreatic duct stones (single 43, multiple 82) treated by interventional endoscopy, including extracorporeal shockwave lithotripsy.

RESULTS

Technical success was achieved in 85% of patients (11 patients by mechanical lithotripsy, 114 by piezoelectric extracorporeal shockwave lithotripsy). There were no serious complications from lithotripsy. Univariate analysis disclosed a statistically significant association between treatment success and patient age as well as prepapillary location of stones. A greater therapeutic effort was necessary in patients with stones located in the tail of the pancreas, 2 or more stones, a stone 12 mm or more in diameter, or who have had a longer duration (>8 years) of the disease. However, with exception of the last parameter, correction for multiple testing of data removed statistical significance.

CONCLUSIONS

Extracorporeal shockwave lithotripsy enhances endoscopic measures for treatment of pancreatic duct stones when mechanical lithotripsy fails. Middle-aged patients in the early stages of chronic pancreatitis with stones in a prepapillary location proved to be the best candidates for successful treatment. Unfavorable patient-related or morphologic factors can be compensated for through more intense efforts at therapy.

Abdominal actinomycosis: complication of endoscopic stenting in chronic pancreatitis?

Pancreatic endotherapy is frequently performed in patients with chronic pancreatitis and stenoses of the main pancreatic duct. In a patient with long-standing chronic pancreatitis and treatment with pancreatic stents, metastatic pancreatic head carcinoma was suspected because of infiltration of the neighboring organs and hepatic lesions. Ultrasound-guided aspiration of one liver lesion revealed grains typical for actinomycosis. In the light of this case, an extracted pancreatic stent was microbiologically investigated for actinomycetes in another patient who had a suspicious lesion of the pancreatic head. Microbiological examination of the extracted pancreatic stent revealed colonization by Actinomyces meyeri, Klebsiella oxytoca, and mixed cultures of anaerobic and saprophytic Gram-positive bacteria. In the following weeks, she developed a septic clinical picture with multiple abscesses of the liver. Actinomyces meyeri, Corynebacterium species, Candida and Enterococcae were cultivated in the aspirates. It seems possible, that treatment with pancreatic stents could have caused invasion of actinomycetes into the parenchyma of the pancreas, which was already harmed by the chronic inflammation, followed by the typical infiltrative growth and hematologic or biliary seeding into the liver.

Acute hepatitis induced by greater celandine (Chelidonium majus)

The hepatotoxic potential of conventional drugs is well known, but herbal medicines are often assumed to be harmless. In the last 2 years, we have observed 10 cases of acute hepatitis induced by preparations of greater celandine (Chelidonium majus), which are frequently prescribed to treat gastric and biliary disorders. The course of hepatitis was mild to severe. Marked cholestasis was observed in 5 patients, but liver failure did not occur. Other possible causes of liver disease (viral, autoimmune, hereditary, alcohol, and secondary biliary) were excluded by laboratory tests and imaging procedures, and liver biopsy specimens were consistent with drug-induced damage. After discontinuation of greater celandine, rapid recovery was observed in all patients and liver enzyme levels returned to normal in 2-6 months. Unintentional rechallenge led to a second flare of hepatic inflammation in 1 patient. Greater celandine has to be added to the list of herbs capable of inducing acute (cholestatic) hepatitis. A significant proportion of unexplained cases of hepatitis may be caused by greater celandine.

[Optimized extracorporeal shockwave lithotripsy of gallbladder calculi: a prospective randomized therapy comparison]

Is "pulverization" or "fragmentation" the best endpoint of extracorporeal shock wave application in ESWL of gallbladder stones? Has gallbladder motility a potential for the prevention of stone recurrence?

METHODS

Prospective, monocentric study with randomization between the conventional treatment strategy (endpoint of shock wave application: fragments < or = 4 mm, concomitant oral chemolitholysis) and an intensified treatment strategy (endpoint of shock wave application: Pulverization, no chemolitholysis). Prevention of stone recurrence: At least once per month for one hour after a meal standardized position (back position, lowered chest).

RESULTS

34 patients, age 46 +/- 14 years (27 women, seven men) were included (F-ESWL: n = 18; P-ESWL: n = 16). Gallbladder motility, number, size and CT-measured calcifications of stones were comparable for both groups. P-ESWL patients received more shock wave pulses than F-ESWL patients and more treatment sessions. P-ESWL resulted in a better fragmentation and pulverization of stones was reached significantly more often (p < 0.05). The time period for stone clearance was significantly depending on the fragmentation result (pulverization: 0.7 months vs. fragments < or = 4 mm: 6.6 months vs. fragments > or = 4 mm: 8.0 months; p < 0.01). The stone free rate after twelve months was 87.5% for P-ESWL and 72.2% for F-ESWL (n.s.) and correlated significantly with the fragmentation result (p < 0.01). Pain sensations during stone clearance were significantly reduced by P-ESWL. Stonefree patients were followed up for 30 +/- 13 months, the total recurrence rate was 7.1%.

CONCLUSIONS

Aiming for pulverization of gallbladder stones by means of intensified extracorporeal shock wave application is at least equal or in tendency superior compared to disintegration to fragements < or = 4 mm. Gallbladder motility might be useful to prevent gallstone recurrence after successful ESWL.

[Augmentation of the immune response to islet cell antigens with development of diabetes mellitus caused by interferon-alpha therapy in chronic hepatitis C]

We report on a 36-year-old patient suffering from chronic hepatitis C. Because of elevated liver enzymes and histology showing chronic inflammation and periportal fibrosis, interferon-alpha (IFN) therapy was started with a dosage of 5 Mio units three times a week. Four months later the patient hat to be hospitalized due to the typical clinical features of a recent onset type 1 diabetes (BG > 300 mg/dl, HbA1c 9.6%, ketonuria). In serum samples prior to and following interferon therapy, we analyzed titers of diabetes-related autoantibodies responding to GAD65 (glutamic acid decarboxylase), IA2c (tyrosine phosphatase) and ICA (islet cell autoantibodies). While ICA were negative before starting therapy, IA2c-antibodies were highly elevated. In contrast. GAD65-antibodies were elevated only slightly over the cut-off of the assay before therapy (controlled by a second different RIA assay) and increased 100 fold during IFN-alpha treatment. Additionally thyroid antibodies appeared. After the end of the IFN therapy, GAD65- and IA2c antibodies remained on high levels and also ICA could now be found. The patient was positive for HLA-DR4. This case supports the hypothesis that IFN-alpha therapy may lead to an augmented autoimmune reaction against islet cell antigens resulting in the development of diabetes mellitus type 1, especially if there are other predisposing factors before IFN treatment. We further discuss the possible involvement of interferon-alpha in the pathogenesis of autoimmune diabetes with reference to recent studies.

[Diagnostic procedure in cholecystolithiasis. Diagnostic approach, repeat examinations and (incidental) findings]

If non-surgical methods are to be taken into account in the therapeutic decision-making process in cholecystolithiasis, an expanded diagnostic work-up including not only stone parameters but also gallbladder function, is needed. In 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) with (suspected) "cholecystolithiasis" attending the special gallstone outpatient clinic at a university medical department within a period of 5 years the diagnostic procedures most commonly used in both the doctor's office and hospital were abdominal ultrasonography (52%/78%), laboratory investigations (28%/39%) and plain films of the biliary tract (27%/39%). In the doctor's office gallbladder function testing took the form of an cholecystogram (17% of the patients); in the hospital ultrasonography to determine gallbladder contractility (38%). With decreasing frequency, the following additional procedures were carried out (office/hospital): CT 3%/19%, esophagogastroduodenoscopy 7%/3%, intravenous cholegram 6%/0.6%, abdominal X-ray 1%/0.4%, ERCP 1%/0.4%, chest X-ray 0.8%/1.6%. Duplicated examinations showed a relevant frequency only for ultrasonography (39% of the cases), laboratory investigations (18%) and plain films of the gallbladder (4%). Pathologic secondary findings were established in 22% of the cases.

[Changes in and acceptance of surgical and noninvasive therapy procedures in cholecystolithiasis]

BACKGROUND

The treatment of cholecystolithiasis has changed fundamentally in recent years due to the development of non-surgical techniques (extracorporeal shockwave lithotripsy [ESWL], oral litholysis) and the implementation of laparoscopic cholecystectomy.

PATIENTS AND RESULTS

Retrospective analysis of 2270 patients (1649 women, 621 men; age: 47.2 +/- 14 years) presenting with gallstone disorders in a university medical outpatients department between 1988 and 1992 in order to be instructed as to the most suitable therapy method bear witness to the rapid change in therapeutic procedure. Laparoscopic removal of the gallbladder has virtually supplanted conventional cholecystectomy, and within 5 years the proportionate role of ESWL has declined from 21 to 12%. Over the years, the proportion of patients requiring no therapeutic intervention remained constant (at about 20%). The therapeutic recommendations of the "experts" were implemented in almost 80% of cases. The majority of patients were satisfied with the chosen therapeutic approach (surgery: 93.0%, ESWL: 77.6%), although 44% of ESWL-patients and 36% of surgically managed patients reported complaints which persisted even after completion of therapy. Despite unsuccessful ESWL (residual fragments or recurrent stones) 58/95 (61%) of interviewed patients would again give preference to this non-invasive modality in the event of a renewed therapeutic decision.

CONCLUSION

Only a few years after its introduction, laparoscopic cholecystectomy has asserted itself as the predominant treatment option. But as far as acceptance and preference by the patient are concerned extracorporeal shockwave lithotripsy--as a non-invasive treatment modality--also enjoys high popularity and can be recommended as an alternative to surgery in suitable patients chosen according to the currently established stringent selection criteria.

[Technical and clinical success with extracorporeal shockwave lithotripsy in pancreatic duct calculi]

BACKGROUND

Chronic pancreatitis is often complicated by concrements obstructing the main pancreatic duct. Duct obstruction is discussed as potential mechanism responsible for recurrent and persistent pain.

PATIENTS AND METHODS

75 symptomatic patients (15 female, 60 male; 46 +/- 12 years) with stones in the main pancreatic duct (solitary n = 23; multiple n = 52) primarily not endoscopically extractable even after sphincterotomy of the pancreatic orifice were treated by means of a piezoelectric lithotripter (Piezolith 2500). Fragmentation and stone clearance were documented by ERP. The clinical benefit was evaluated in 35 patients (9 female, 26 male; 45 +/- 12 years) followed up meanwhile for more than 12 (29 +/- 14) months.

RESULTS

After 3 +/- 2 (1 to 10) ESWL-sessions/patient the concrements were fragmented successfully in 80% of the patients. Focussing of the stones was achieved sonographically (15%), fluoroscopically (45%) or using both imaging techniques (40%). In total, 61% of the patients became stone free, 44% spontaneously, in further 17% all remaining fragments could be removed endoscopically. In 39% of the patients only a partial extraction was achieved. Severe complications due to shockwave application did not occur. The majority of the patients (stonefree n = 22, remaining fragments n = 13) followed up > or = 12 months kept free of pain (51%) or reported on pain relief (26%). Nine patients developed 13 recurrent calculi, which were again treated successfully by interventional measures in 8/9 patients.

CONCLUSIONS

The data confirm the value of extracorporeal shockwave lithotripsy as an important tool in the interventional therapy of chronic pancreatitis. Even if recurrent calculi may occur, the majority of patients will experience at least a medium-term profit by those measures due to pain relief.

[Cost comparison of laparoscopic cholecystectomy and extracorporeal shockwave lithotripsy in the treatment of gallstones]

To aid in the choice between laparoscopic cholecystectomy and extracorporeal shock wave lithotripsy for the treatment of gallstones the costs of the two methods were investigated. A decision tree was constructed so as to set out the initial procedure costs of both techniques and possible subsequent costs due to treatment failure or complications. The computations were based on figures from the University Clinic, Erlangen, in 1993. The direct (medical) costs of laparoscopic cholecystectomy amounted to DM 3556, to which must be added further indirect costs of DM 3152 arising from loss of working capacity and premature death. The direct expenses for lithotripsy including outpatient aftercare were DM 6708 and the indirect expenses DM 1858. The overall costs per patient for lithotripsy are hence DM 1858 higher than those of laparoscopic cholecystectomy. This cost difference remained substantially unaltered even when the success rates of the two techniques were varied over a wide range. When lithotripsy is performed entirely as an outpatient procedure and inpatient costs hence disappear, the expected overall cost drops from DM 8567 to DM 6381. Omission of the lump sum charge for lithotripsy effects a similar drop in overall costs to DM 6379. Laparoscopic cholecystectomy is hence cheaper than lithotripsy. Only if lithotripsy can be performed at very low cost can it compete with laparoscopic cholecystectomy.

Piezoelectric shock wave lithotripsy of pancreatic duct stones

OBJECTIVES

The efficacy of extracorporeal piezoelectric shock wave lithotripsy in patients with obstructing pancreatic duct stones was investigated.

METHODS

Fifty patients suffering from chronic pancreatitis and obstructing pancreatolithiasis were treated by ESWL (Piezolith 2500). Shock wave treatment was administered, inasmuch as the stones were not extractable by initially applied endoscopic measures.

RESULTS

A total of 119 (2.4 +/- 1.4, range 1-7) lithotripsy sessions were conducted; only mild sedation/analgesia was used. Optimum targeting of the concrements in the shock wave focus was achieved in 17 (14%) treatment sessions with ultrasonography only; it was achieved in 65 (55%) cases by fluoroscopy and, in further 37 (31%) sessions by using both localization systems. Stone fragmentation was successful in 43 (86%) patients. Nineteen (38%) patients achieved spontaneous stone discharge after shock wave lithotripsy. In 11 (22%) cases, it was possible to remove all fragments endoscopically; residual fragments remained in 20 (40%) patients. Severe complications attributable to shock wave application did not occur. During follow-up, six patients had to be referred to surgery; two male patients died of specific diabetic complications and pleural mesothelioma, respectively. Thirty-five (90%) of 39 patients whose conditions were followed for 2-50 (20 +/- 14) months reported improvement of their pain sensations. Six (15%) patients required endoscopic treatment, including ESWL in five of those patients, to be repeated due to recurrent formation of calculi in the main pancreatic duct, which was again successful in five of the six patients.

CONCLUSIONS

Piezoelectric shock wave lithotripsy offers a basis for safe and effective fragmentation of pancreatic stones and facilitates endoscopic procedures. Most of the patients with obstructing pancreatic stones became stonefree and showed a significant reduction of pain.

Recurrent gallstone formation after successful extracorporeal shock-wave lithotripsy

Gallstone recurrence was evaluated in 184 patients exhibiting complete stone disappearance after successful extracorporeal shock-wave lithotripsy (ESWL) and concomitant oral bile acid therapy. Follow-up examinations conducted 6-43 months after termination of adjuvant bile acid therapy revealed recurrent calculi in 40/184 (21.7%) patients (27 females, 13 males, p < 0.01; 13 patients with solitary, 27 patients with multiple stones) after a median stone-free period of 11 months (range 1-33 months; mean +/- SD, 13 +/- 8 months). Therefore, an overall probability of stone recurrence of 11.8% was observed 12 months after complete stone disappearance had been confirmed sonographically and bile salt therapy terminated, and a probability of 25.5% after 24 months. Gallstone reformation occurred in 30/146 (20.5%) patients with initially solitary and 10/38 (26.3%) patients with multiple calculi [not significant (NS)]. Only 3/40 (8%) patients with recurrent calculi reported biliary colic. Sonographic gallbladder contractility values acquired at the time recurrent stones were detected did not show any significant differences, compared with the data obtained in the pretreatment examinations; neither were any differences noted between the patients with gallstone reformation and those who remained stone-free. In 20/33 (61%) patients with recurrent stones who opted for further conservative retreatment (ESWL and/or oral litholysis), complete stone disappearance was achieved a second time. The recurrence rates achieved within the first 3 yr after successful shock-wave lithotripsy of biliary calculi cover a range similar to the rates noted after dissolution therapy.

A clinical comparison of an electrohydraulic and a piezoelectric shockwave lithotripter in gallstone therapy

The aim of this prospective, randomized study was to compare two second-generation lithotripters based on different physical principles in patients with gallbladder stones at a single lithotripsy center under the same clinical conditions. Sixty patients with one to three symptomatic gallbladder stones were selected for lithotripsy, either with an electrohydraulic or a piezoelectric device. With both lithotripters, treatment was performed under standard conditions (prone position, sonographic monitoring, sedoanalgesia if necessary, up to 3000 pulses/session, retreatments (maximum, two) if fragments > 4 mm, concomitant oral chemolitholysis). If no fragmentation could be obtained in the first session, the other lithotripter was used for the following treatments. The two groups did not differ significantly with regard to the anthropometric data or number and size of stones. In contrast to piezoelectric lithotripsy (0%), with the electrohydraulic lithotripter, iv analgesics and sedatives were necessary in all treatments (100%); however, in 11/53 treatments (21%), patients did not tolerate the full session despite maximum medication. The treatment time was nearly twice as long with electrohydraulic (56 +/- 22 min) than with piezoelectric lithotripsy (31 +/- 8 min) (p < 0.001). With the electrohydraulic lithotripter, used in 20% of the patients, no fragmentation was seen after the first session, and therapeutically adequate fragmentation (< or = 4 mm) occurred in only 33%. In contrast, with the piezoelectric lithotripter, the stones were disintegrated in all patients (p < 0.05); in 50% a maximum fragment size < or = 4 mm was measured after the first treatment. Whereas in the first months after lithotripsy, stone-free rates were higher with piezoelectric lithotripsy (43% vs. 25% after 1 month; 47% vs. 38% after 2 months; 60% vs. 48% after 4 months; NS), rates of complete stone disappearance were equally high in both groups after 12 months (82%).

[The piezoelectric lithotripsy of gallstones. The acute- and long-term results]

Extracorporeal piezoelectric lithotripsy (PEL) with oral lysis (about 7.5 mg/kg urso- and chenodeoxycholic acid as single dose in the evening) was performed, according to a standardized treatment and follow-up protocol, in 219 patients (177 women, 42 men; aged 47 +/- 14 years) with symptoms of gallbladder stones. The average number of treatment sessions per patient was 2.0 +/- 0.8. Significantly fewer sessions with fewer shockwave charges were required in solitary gallstones of less than or equal to 20 mm diameter than in those of greater than 20 mm diameter and in multiple concrements (P less than 0.01). Fragmentation was successful in 99% of patients. Sedation and/or analgesia during PEL were required in only 2% of patients. There were no marked side effects during the treatment. The stone-free rate 12 months after the start of treatment was 76% in the group with solitary stones less than or equal to 20 mm, 75% with solitary stones greater than 20 mm and 64% for multiple stones. During the follow-up period 36% of patients had biliary colics and 3% had fragments impacted in the common bile duct. Biliary pancreatitis occurred in 1% of patients. PEL is an effective and sparing procedure in the treatment of selected patients with gallbladder stones.

Shockwave lithotripsy of salivary duct stones

Surgical extirpation of the affected gland has been necessary for cases of sialolithiasis in which the stone cannot be removed by dilatation or dissection of the salivary duct. The ability of the piezoelectric lithotripter to deliver shockwaves to a small focus makes extracorporeal shockwave lithotripsy of salivary gland stones potentially safe. Its safety and efficacy have been assessed in 51 patients with symptomatic solitary salivary stones that could not be removed by conservative measures. The stones had a median diameter of 8 (range 4-18) mm and were located in the submandibular gland in 69% of patients and in the parotid gland in 31%. A total of 72 shockwave treatment sessions (maximum 3 per patient) were given under continuous sonographic monitoring. In 45 patients (88%) complete fragmentation (fragments less than or equal to 3 mm) of the concrements was achieved. No patient needed anaesthesia, sedatives, or analgesics. The only untoward effects were localised petechial haemorrhages after 10 (13%) out of 72 treatments and transient swelling of the gland immediately after delivery of shockwave in 2/72 (3%) sessions. 20 weeks after the first session 90% (46/51) of patients were free of discomfort, and 53% (27/51) were stone free. Stone-clearance rate was higher among patients with stones in the parotid gland (81%) than among those with stones of the submandibular gland (40%). Auxiliary measures such as dilatation or dissection of the salivary duct were required only in patients with stones in the submandibular gland (20%). No long-term damage to the treated salivary gland or to adjacent tissue structures was noted during the median follow-up of 9 (1-24) months. Extracorporeal piezoelectric shockwave therapy seems likely to be safe, comfortable, and effective minimally-invasive, non-surgical treatment for salivary stones.

Extracorporeal piezoelectric shock-wave lithotripsy of salivary gland stones

Piezoelectric lithotripsy was undertaken on 19 patients with salivary stones, with none of these patients requiring anesthesia, analgetics, or sedatives. All salivary stones were totally fragmented during first lithotripsy. Four months after treatment with extracorporeal shock waves, all patients were free of symptoms and, in 11 of the patients, no calculi could be found sonographically. The piezoelectric lithotripsy of salivary stones caused no serious side effects which could be proven by clinical, biochemical, sonographic, and magnetic resonance imaging (MRI) examinations. Extracorporeal piezoelectric lithotripsy is a new and promising nonsurgical therapy for selected cases of sialolithiasis of the parotid and submandibular glands.

Extracorporeal piezoelectric shock wave lithotripsy of salivary gland stones: first clinical experiences

Piezoelectric lithotripsy was undertaken on 14 patients with salivary stones, none of them requiring anesthesia, analgesics, or sedatives. All salivary stones were fragmented totally during the first lithotripsy session. Four months after treatment with extracorporeal shock waves all patients were free of symptoms, and in seven out of 14 patients no concrement could be found sonographically. The piezoelectric lithotripsy of salivary stones had caused no serious side effects proved by clinical, biochemical, sonographic, and magnetic resonance imaging examinations. Extracorporeal piezoelectric lithotripsy is a new and promising nonsurgical therapy for selected cases of sialolithiasis of the large salivary glands.

Significance of computed tomography for shock-wave therapy of radiolucent gallbladder stones

One hundred eleven symptomatic patients (91 women, 20 men) with solitary "radiolucent" stones (proved by a plain radiograph) underwent examination with computed tomography for stone analysis before extracorporeal shock-wave lithotripsy with a second-generation piezoelectric lithoptripter. The aim of the study was to assess the importance of computed tomography as a diagnostic pretreatment procedure compared with the plain abdominal radiograph: computed tomography density values greater than 50 Hounsfield units (HU) were found in 64 of 111 patients with radiolucent stones (58%). Of these 64, 50 patients even had values greater than 90 HU (50/111;45%). The majority of the stones with density values greater than 50 HU had a hyperdense rim (43 of 64) with a mean maximum attenuation of 134 +/- 68 HU. A significantly higher degree of stone disintegration was achieved with stones of group A (less than or equal to 50 HU) than with those in group B (greater than 50 HU and less than or equal to 90 HU) and group C (greater than 90 HU) with respect to the mean maximum fragment size after the first (P less than 0.001) and last (P less than 0.01) lithotripsy and with respect to the total number of shock waves applied (P less than 0.001) and the number of treatments (P less than 0.001). No difference was observed between groups B and C. After all follow-up periods, the rate of complete stone disappearance was higher in group A than in group B (NS for 1, 2, and 4 months of follow-up; P less than 0.01 for month 8; P less than 0.05 for month 12) and group C (P less than 0.05 for 1, 2, and 4 months of follow-up; P less than 0.001 for months 8 and 12). The authors conclude that computed tomographic analysis of gallstones before lithotripsy is more sensitive in detecting nonradiolucent stones than in the plain radiograph. Computed tomographic stone analysis seems to provide a better selection of patients suitable for biliary lithotripsy and could become a standard diagnostic pretreatment procedure to improve stone disintegration and complete stone disappearance after shock-wave lithotripsy and adjuvant chemolitholysis.

[Imaging procedures prior to the extracorporeal shockwave lithotripsy of gallstones]

In order to determine whether cholecystography and computed tomography (CT) are capable of better gallstone characterization than conventional radiography alone, 91 patients (76 females, 15 males; mean age 47 +/- 12 years) with symptomatic single gallstones were studied prospectively prior to extracorporeal shock-wave lithotripsy with concomitant oral stone dissolution therapy. In addition, the value of oral cholecystography in demonstrating patency of the cystic duct was compared with ultrasound assessment of gallbladder function. Despite "negative" plain gallbladder radiographs in all patients, oral cholecystography showed significant stone calcification in 8 of the 91 patients and CT showed stone calcifications in 52 of the 91 patients. In 12 patients the maximum stone density was between 50 and 90 Hounsfield units, and in 40 patients it was more than 90 Hounsfield units. CT revealed ring-like calcification in the majority (79%) of these stones. Oral cholecystography showed satisfactory concentration of contrast medium in all patients, while ultrasonography of the gallbladder following a chemically defined test meal demonstrated contractility of more than 50% of initial volume in 69 patients and of less than 30% in 9 patients. Although oral cholecystography is a simple, readily available complication-free method, ultrasound assessment of gallbladder contraction is better for selecting patients for extracorporeal shock-wave lithotripsy. CT allows significantly better characterization of gallstones than oral cholecystography and conventional plain gallbladder radiography.

Piezoelectric lithotripsy: stone disintegration and follow-up results in patients with symptomatic gallbladder stones

One hundred symptomatic patients with radiolucent gallbladder stones were treated with a new piezoelectric lithotripter and oral chemolitholytic agents. Stone disintegration was achieved in 99 of these patients (99%) with a mean (+/- SD) maximum fragment size of 5.1 +/- 4.1 mm. Significant differences were found when the mean (+/- SD) fragment sizes of single stones less than or equal to 20 mm (4.2 +/- 2.5 mm) were compared with those of single stones greater than 20 mm (5.8 +/- 3.4 mm; P less than 0.05) and multiple stones (6.2 +/- 3.8 mm; P less than 0.05), respectively. None of the patients required anesthesia, analgesics, or sedatives before or during the treatment. The stone-free rates for all patients followed up for up to 4-12 months (mean +/- SD, 10.7 +/- 2.9 months) were 18% (1 month), 25% (2 months), 38% (4 months), 52% (8 months), and 67% (12 months). Partly significant differences were obtained in stone-free rates for single stones (less than or equal to 20 mm) compared with larger stones (greater than 20 mm) and multiple stones (P less than 0.05), respectively. Serious adverse reactions (i.e., cholestasis and pancreatitis) were observed in only 3 patients (3%). These conditions were induced by fragment impaction in the common bile duct. In 2 of these patients, endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy was required. It is concluded that piezoelectrically generated shock waves are suitable for the effective and safe disintegration of gallbladder stones in humans. The anesthesia-free and analgesia-free shock-wave application opens up the possibility to perform biliary lithotripsy as an outpatient procedure. The stone-free rate achieved in combination with oral bile acids is most promising for single stones (less than or equal to 20 mm).