Stratification of gallstone fragments: the key to more effective fragmentation.

During previous experiments with in vitro fragmentation in a simulated gallbladder, we noticed that stone fragments tended to stratify with the dust and smaller fragments settled to the dependent portion, while the larger fragments settled on top. We reviewed the oral cholecystogram (OCG) of 10 patients examined 6 months following gallstone lithotripsy. In all cases with adequate visualization of stone fragments, the stratification phenomenon was observed. We hypothesized that adjusting the shock wave focus to target on these large fragments would improve the efficiency of fragmentation. To test this hypothesis, we fragmented three matched pairs of gallstones in vitro. For each pair, the stones were removed from the same gallbladder and the stone weights of the two stones were within 10%. The smaller member of each pair was fragmented using the "old method" with the focus on the fragment line. The larger stone was fragmented with the "new method" with the focus in the acoustic shadow deep to the echogenic line caused by the dust and small fragments in the dependent portion. The distribution of fragments was analyzed by passing the fragments through a series of filters. With the new method of targeting, the proportion of fragments less than 1.5 mm was doubled while the fragments greater than 5 mm were eliminated. The new method of targeting, taking into account the stratification of stone fragments, produces more effective fragmentation and should lead to more rapid clearance of fragments from the gallbladder.