The Journal of lithotripsy & stone disease最新文献

To assess the reliability of ultrasound in measuring a minimum stone fragment burden we implanted radiolucent human gallstone fragments measuring from less than 1 mm up to 4 mm in size into the gallbladders of 12 domestic piglets. Forty-eight hours later the fragments in each animal were assessed by a qualified radiologist using two different ultrasound machines in a randomized blinded fashion. With regard to size estimation using a 5 MHz sector scanner, in two out of 12 examinations there was an overestimation of fragment size such that in a clinical setting an unneccessary repeat lithotripsy session would have been requested. A 5 MHz linear array transducer was of sufficient reliability in all size estimations not to have resulted in such a request. No gallbladder was falsely declared fragment free. There were nonshadowing fragments present in five of 12 examinations using both transducers. Clumping of small fragments less than or equal to 3 mm was present in two examinations. We recommend that a second ultrasound examination is performed when the presence of clumping is suspected and also when a fragment-free gallbladder is initially diagnosed.

The introduction of "nonoperative" treatment alternatives to elective cholecystectomy (extracorporeal shock wave lithotripsy, contact dissolution of stones, and improved oral bile salts solvents) has reinstated the oral cholecystogram as an important diagnostic test providing structural and functional information on the status of the gallbladder. The basic principles involved in the proper performance and interpretation of the oral cholecystogram are reviewed from the perspective of the clinician who orders the test and makes management decisions based on its results.

The feasibility of fragmentation of salivary stones by a new extracorporeal piezoelectric lithotripter was investigated. A total of 40 salivary stones were submitted to piezoelectric shock wave treatment. The diameter, weight, and volume of all the stones were determined prior to shock wave administration. After shock wave administration the chemical composition of the stones was investigated by X-ray diffractometry. Fragmentation was achieved in 35 out of the 40 (87.5%) stones. Twenty-five of the 40 (62.5%) stones were disintegrated "therapeutically adequate" (residual fragments less than 1.5 mm). A statistically significant correlation was not observed between the number of discharges required for disintegration and the diameter, weight, volume, or the chemical composition of the stones.

From March, 1988 until October, 1989, 502 patients with 603 stones were treated with the Dornier multipurpose lithotripter MPL 9000. Sixty-six percent of the stones were situated in the calix, 29.6% in the renal pelvis, 3% in the upper, and 1% in the distal ureter; 18.4% of the stones were radiolucent. Multiple MPL treatments were performed in 8.6%. In 6.1% fragments post-ESWL treatment were larger than 5 mm. In 58.6% of the treatments were performed without using analgesia or anesthesia. Intravenous anesthesia was used in 22.3%, analgesia and sedation in 16.9%, general anesthesia in 1.4%, and epidural anesthesia in 0.8%. After 3 months follow-up 73.1% were stone-free. Residual fragments were found in the upper calix in 1.1%, in the middle calix in 5.2%, in the lower calix in 13.4%, in the renal pelvis in 5.9%, and in the ureter in 1%. The MPL 9000 has been proven to be as effective for the treatment of renal stones, while difficulties in localizing ureteral stones were noted. The major number of treatments were performed without any analgesia or anesthesia. No major complications were encountered.

Thirty patients with partial or total staghorn lithiasis or calculi larger than 30 mm were treated by piezoelectric lithotripsy (PEL) monotherapy using an EDAP LT-01 lithotripter with ultrasound guidance. Nineteen of these patients had a pelvic stone; the other 11 had partial (nine) or total (two) staghorn lithiasis. All patients first underwent an initial lithotripsy session. No anesthesia or intravenous sedation was required in any case. If stone fracturization was achieved after this first session, a double J stent was inserted before the second lithotripsy session. Prior to the first session, 18 of 30 patients had a sterile urine culture; 12 of 30 presented major distention of the excretory tract. Results were analyzed to determine those factors influencing the outcome of this therapy. Three months after the first session, patients were considered cured if their stone had completely disappeared on abdominal plain films (14/30 = 46%). In seven patients (23.3%), fracturization had occurred but residual fragments remained (1-3 fragments less than or equal to 4 mm). No fracturization was obtained after the first session in nine patients (30.7%) (one total staghorn lithiasis, eight pelvic stones). The mean number of treatment sessions was five (range 1-15). Complications occurred in only 10% of patients (3/30): two steinstrasse and one acute pyelonephritis. Eighty-three percent of patients without major excretory tract distention and 55% of patients whose initial urine culture was sterile, achieved a stone-free state.(ABSTRACT TRUNCATED AT 250 WORDS)

Extracorporeal shock wave lithotripsy (ESWL) has been established as a standard method of urinary stone treatment. Poor fragmentation with an increased rate of complications has been noticed with certain calculi types (calcium oxalate monohydrate and cystine). In devising appropriate pre-operative strategies, it would be useful to know the calculi composition. We have investigated the in vitro utility of using magnetic resonance imaging (MRI) in analyzing urinary calculi. Our in vitro analysis found no difference in signal characteristics between calculi of varying composition. The absence of signal can be understood from a molecular basis. We conclude that MRI will not offer any assistance in characterizing the composition of urinary calculi.

As the Food and Drug Administration trials for biliary lithotripsy in the United States near completion, future criteria for patient eligibility remain to be defined. Gallstone calcification greater than 3-mm partial rim on plain film (KUB) or oral cholecystogram (OCG) has excluded patients thus far, since early results of gallstone clearance (lithotripsy plus chemodissolution) were suboptimal with calcified stones. To evaluate the usefulness of these criteria for gallstone fragmentation, computed tomographic (CT) scans were performed on 20 patients immediately prior to lithotripsy to evaluate gallstone density and 24 hours after lithotripsy to observe the CT appearance of fragmentation. The adequacy of fragmentation was determined by pre- and post-lithotripsy sonography. This report constitutes the results of these investigations.

Thirty-six patients with radiopaque calculi in the segment of the ureter overlying the sacrum, were treated in the prone position with an unmodified Dornier HM-3 lithotripter. Thirty-one treatments were successful and five failed for a success rate of 86%. Success is defined as the absence of fragments on KUB. The five failures were all removed ureteroscopically. Epidural anesthesia was used for all cases. A post-extracorporeal shock wave lithotripter (post-ESWL) gastrointestinal (GI) bleeding episode, and an upper ureteral extravasation post-ESWL, as well as two patients who could not tolerate the position are discussed.

Evaluating the economic impact of medical procedures is of increasing importance in the American health care system, and this is especially true in the case of new medical technologies. Both the cost and the outcome of a treatment, and its alternatives must be evaluated. A cost-utility analysis was performed to compare cholecystectomy with biliary lithotripsy accompanied by bile acid therapy. Using a Markov approach, a model was designed to project expected cost and quality-adjusted survival over a 5-year period in patients with solitary stones of less than or equal to 20 mm in diameter. The viewpoint of the analysis was chosen to be that of the general society, since it can be considered as a consensus of all interest groups. Direct costs were obtained from hospitals in Atlanta, Georgia; indirect costs are based on average United States earnings. Utility was estimated using a model that combines different scales of well-being with an underlying etiology. The findings indicate that from society's point of view for all patients meeting lithotripsy inclusion criteria, based on this cost-utility analysis, biliary lithotripsy would be the procedure of choice.