Gallstone lithotripsy.

ESWL, in its present state of technology, is unlikely to displace endoscopy as the treatment of first choice for common duct stones present after cholecystectomy, since endoscopic sphincterotomy is necessary to enhance passage of stones from the ductal system. However, when endoscopy fails, ESWL may prove a useful adjunctive treatment for both choledocholithiasis and intrahepatic stones. ESWL for gallstones is currently an evolving treatment option for patients with symptomatic gallstones. On the basis of data presented, its efficacy for fragmenting stones seems established, as does its safety using current guidelines. There is a high rate of success in patients with one or several small cholesterol gallstones. Although definitive proof has yet to be established, it is widely believed that the use of adjuvant bile salt therapy is essential for improving the clearance and dissolution of fragments resulting from ESWL. ESWL for gallstones, of all the nonsurgical treatments, seems to have the greatest advantage as an alternative to surgical intervention since it is the least invasive and can be performed in the ambulatory setting. In comparing ESWL to cholecystectomy, it holds the potential major advantages of being an outpatient treatment, keeping time off from work to a minimum, and being extremely well tolerated by and much less painful for a patient. Its major disadvantages at this time include its applicability to only a small segment of the patients with gallstones. Like all other nonsurgical treatments, it is also not a definitive treatment of gallstones, recurrent stone formation rates possibly being as high as 50 percent or more within 5 years of treatment. In today's scheme of health care delivery, the use of ESWL may ultimately depend on the willingness of the public or health care system to bear the additional costs of multiple treatments of gallstones during a person's lifetime as opposed to one definitive operation with its associated discomforts and temporary disability. The emergence of ESWL for treating gallstones has resulted in a not unexpected criticism, though probably a healthy criticism from the surgical community in general. However, as emphasized in a recent editorial, we surgeons owe it to our patients to be prepared to offer the best suitable treatment for their condition. ESWL in its present state may be that treatment for only a few patients with gallstones, but advancing technology could increase its applicability. Surgeons should therefore continue to lead by knowing how to use lithotripsy to treat cholelithiasis.