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Background and Study Aim: Choledocholithiasis is a common disease in the West. Lithotripsy by mechanical methods using baskets and by laser or electrohydraulic methods varies in effectiveness. With argon plasma coagulation (APC), high temperatures are used for devitalization and fragmentation; cryogenic techniques use the selective controlled application of freeze-thaw cycles to devitalize pathological tissue; and the dissecting water jet exploits the high pressure action of a thin laminar jet. We aimed to assess the feasibility and effectiveness of APC, cryotechnology, and the dissecting water jet as options for the fragmentation of bile duct stones., Methods: In an in vitro feasibility study, we evaluated the fragmentation of 120 bile duct stones treated with the three methods. Primary measures were assessment of the fragmentation rate, fragmentation effect, and energy application for each technology., Results: Fragmentation was seen in only 10 % of stones treated cryogenically using liquid nitrogen. APC at a power setting of 30 - 50 W fragmented all the cholesterol stones, but results with hard pigment stones were unsatisfactory even at high energies of a 100 W setting and long application time. Using the water jet, all 40 stones (100 %) were cracked effectively and completely with a pressure of 10 - 50 bar., Conclusion: In this feasibility study, the first of its kind, only the water-jet device demonstrated efficient fragmentation of large bile duct stones in vitro. APC and cryotechnology are not suitable for the treatment of bile duct stones; the fragmentation rate with these methods was inadequate.

Extracorporeal shock wave lithotripsy (ESWL) is effective in the treatment of symptomatic cholecystolithiasis in well-selected patients. We analyzed the predictors of cholecystectomy in a large series of gallstone patients after ESWL. This was a retrospective follow-up cohort-study of consecutive patients undergoing ESWL for symptomatic cholecystolithiasis over a 9-year period. It was possible to analyze a total of 297 patients; there were 211 women and 86 men, with a mean age of 52 years (range, 8-81 years). Patients that had been cholecystectomized after ESWL were compared to patients with their gallbladder still in situ and determinants of cholecystemctomy in terms of clinical, stone, and gallbladder parameters and symptoms analyzed. The mean duration of follow-up was 99 months (range, 27-134 months). During follow-up, 106 (36%) patients underwent a cholecystectomy at a mean of 34 months (range, 0-127 months) after ESWL. Histological data showed a normal gallbladder wall in only 4 cases; 101 examinations revealed some kind of (chronic) inflammation, which was not different from histological gallbladder results in patients without prior lithotripsy. Three gallbladder polyps were found, but no carcinoma. Cholecystectomy after ESWL of gallbladder stones was strongly associated with persitent and/or renewed biliary symtoms. Nevertheless, only three of four patients became asymptomatic after CE. Thus, ESWL proved to be a valuable organ-preserving alternative to cholecystectomy in selected patients.

Background and Study Aims: The use of endoscopic therapy in combination with lithotripsy techniques has become increasingly common in patients with complicated common bile duct stones. In many units, although this is controversial, cholecystectomy is then performed, because of possible subsequent cholecystitis and recurrence of choledocholithiasis. The aim of this study was to investigate whether gallbladder status influences the long-term outcome in patients after extracorporeal shockwave lithotripsy (ESWL) of common bile duct stones., Patients and Methods: Recruited for the study were 120 patients with an average age of 68 years (range 28 - 86). They were selected from 137 consecutive patients who presented to our department between January 1989 and June 1996 with complicated common bile duct stones, and in whom ESWL was necessary to achieve complete clearance of stones. Follow-up data were obtained from the patients and their general practitioners., Results: The mean duration of follow-up was 4 years (range 3 - 9). A total of 37 patients had their gallbladder in situ (group A), while 83 had undergone cholecystectomy. Of these 83 patients, 27 had had a cholecystectomy after ESWL (group B), whereas 56 patients had already had the gallbladder removed when choledocholithiasis was diagnosed (group C). During follow-up, 36 patients (30 %) experienced some biliary symptoms. There were no significant differences in the incidence of recurrent biliary symptoms between the three groups. Re-exploration of the bile duct by endoscopic retrograde cholangiopancreatography (ERCP) revealed 28 cases of recurrent bile duct stones. Recurrence developed more often in groups B and C, who had undergone cholecystectomy, without reaching statistical significance ( P = 0.077). In patients with an intact gallbladder (group A), there was no difference in the rate of recurrent biliary symptoms or stones between the patients with or without cholecystolithiasis. Operations were necessary in 28 patients; in only ten was this for biliary reasons., Conclusion: The intact gallbladder is not a risk factor for recurrent biliary complications after ESWL of common bile duct stones; therefore, as far as patients with complicated bile duct stones which require additional lithotripsy techniques are concerned, elective cholecystectomy after endoscopic clearance of the bile duct no longer seems appropriate.

Incarceration of a pancreatic stone fragment in the distal pancreatic duct after ESWL-therapy.A partial or total absence of stones in pancreaticolithiasis therapy can be reached by using ESWL. We report on a patient who happened to get an incarceration of a fragment in the distal pancreatic duct after having been treated by ESWL without a previous sphincterotomy to the ductus Wirsungianus. This emphasizes the recommendation to carry out a papillotomy of the pancreatic main duct before applying ESWL to pancreatic stones.

A 75-year-old man with right upper quadrant abdominal pain was diagnosed by gastroscopy to have an impacted gallstone in the duodenal bulb. Using the polypectomy loop, the stone was extracted from the bulbus and mobilized into the stomach. After failure to remove the stone from the stomach as well as fragmentation by mechanical lithotripsy, electrohydraulic lithotripsy was used to break up the stone, parts of which passed spontaneously through the bowel. Thus, it was unnecessary to proceed with surgical enterolithotomy to remove, from the duodenal bulb, the impacted gallstone responsible for the gastric outlet obstruction.

Background: Intrahepatic lithiasis still is a complicated disease and merits special attention during therapeutic intervention. Although resection of the affected liver lobe or segment is the best therapeutic option to completely remove the source of recurrent infection, the need for endoscopic treatment modalities is evident because hepatic resections are combined with a high morbidity and mortality rate., Methods: Over a 10-year period (1988-1997) 55 patients with intrahepatic stones that were not accessible to routine endoscopic extraction were treated at our department. These patients underwent either extracorporeal shock-wave lithotripsy (n=27) or intracorporeal electrohydraulic (n=12) or laser lithotripsy (n=16)., Results: Using these techniques, we achieved stone fragmentation in 33.3%, 41.6%, and 75%, respectively. With a combination of the different methods, more than 90% of intrahepatic stones could be removed endoscopically. Overall complication rate was 12.7%; complete recovery was achieved in all patients with conservative management., Conclusion: The endoscopic approach to intrahepatic lithiasis appears to be a useful alternative to surgery, with a lower morbidity and mortality. If endoscopic therapy fails, surgery is still possible.

Background: There have been conflicting reports as to whether pancreatic ductal drainage achieved by endoscopy and lithotripsy improves the clinical outcome of patients with chronic pancreatitis., Aims: To determine the clinical outcome in patients with chronic pancreatitis who received extracorporeal shock wave lithotripsy (ESWL), and were followed up for two to eight years., Methods: Eighty patients with severe chronic pancreatitis and endoscopically unretrievable obstructive stones underwent ESWL with a piezoelectric lithotripter between 1989 and 1996. Clinical status, relief of symptoms, further endoscopic or surgical interventions, and mortality were defined., Results: Forty three (54%) patients were treated successfully with ESWL. The only feature associated with treatment success was the presence of a single stone rather than multiple stones. Successfully treated patients tended to experience less pain, although this did not reach statistical significance. A slight increase in weight was noted in our patients; however, there was no notable improvement in anomalous stools and diabetes mellitus. Five patients died due to extrapancreatic reasons. No pancreatic carcinomas developed., Conclusions: ESWL associated with endoscopic drainage is a safe technique that is particularly successful in patients with a single stone. However, pancreatic drainage by endoscopy and ESWL has almost no effect on pain in chronic pancreatitis. Furthermore, endoscopic management and ESWL does not prevent or postpone the development of glandular insufficiency.

Aim: Most patients with pancreatic duct stones have been treated with lithotripters that use x-ray for stone targeting. We wanted to evaluate ultrasound guided lithotripsy in clinical use., Methods: In a prospective clinical study 80 patients (62 men) with symptomatic obstructive chronic pancreatitis were treated with a piezoelectric lithotripter under ultrasound guidance (two in-line 4-MHz-Scanners)., Results: Stone targeting by ultrasound guidance was possible in 76 patients. Fragmentation succeeded in 53 patients (70%). Complete or partial stone clearance was achieved in 43 patients, a success rate of 54%., Conclusion: Ultrasound guided shock wave lithotripsy of pancreatic duct stones plays an important role in the treatment of chronic pancreatitis.

Introduction: More than 97% of common bile duct stones can be successfully managed by endoscopic papillotomy, mechanical lithotripsy and extracorporeal shock-wave lithotripsy. In this study, we evaluate the role of laser lithotripsy after failure of the above mentioned endoscopic methods., Patients and Methods: Eighteen patients (15F, 3M; median age = 69 (28-83) years) were treated by endoscopic laser lithotripsy after ESWL failure. We employed a Rhodamine-6 G laser with a stone-tissue recognizing system. The laser fibers were cholangioscopically (direct vision) or blindly (under plain fluoroscopic control) placed., Results: Seventeen patients were treated endoscopically and one was successfully managed percutaneously after failure of the transpapillary approach. Fourteen (78%) were stone-free after a mean of 1.56 laser therapy sessions alone. Two additional patients were successfully managed after partial fragmentation with combined treatment (mechanical lithotripsy: n = 1, electrohydraulic lithotripsy: n = 1). Overall, 89% of the patients were freed from their calculi. Cholangitis occurred once and the mortality was zero., Conclusions: We conclude that laser lithotripsy is an effective and safe treatment alternative in a highly selected patient population with difficult bile duct stones and considerable surgical risk.

Background: Endoscopic management of common bile duct stones has become the approach of choice, especially in patients with high surgical risk. Problems are encountered if there are large stones or a duct stenosis. For these difficult stones, shock wave technology serves as an alternative to surgical intervention., Methods: A total of 125 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected and treated either by extracorporeal piezoelectric lithotripsy (ESWL, n = 79) or intracorporeal electrohydraulic lithotripsy (EHL, n = 46). The average age of our patients was 70 years., Results: In the ESWL group visualization of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%); stones could be fragmented in 68 patients. The biliary tree could then be completely freed of calculi in 62 of 79 patients, a success rate of 78.5%. In the EHL group, stones were successfully fragmented in 38 of 46 patients; 34 patients (74%) eventually became stone free. Thirty-day mortality was zero in both groups. Combined treatment including ESWL, EHL, and intracorporeal laser lithotripsy was finally successful in 118 patients (94%)., Conclusions: Endoscopic management in combination with the lithotripsy techniques described can be recommended as the method of choice for treating difficult common bile duct stones. A success rate of almost 100% and a mortality rate of 0% is now the established standard, even in elderly and unstable patients.

Objective: Considerable information is presently available about stone-free rates after extracorporeal shock wave lithotripsy (ESWL) of gallbladder stones. Another important item and one that has been poorly investigated is symptom relief after successful ESWL. The aim of the present trial was to determine the course of biliary and gastrointestinal symptoms after successful ESWL of gallstones., Methods: Ninety patients were followed for an average of 18 months after stone disappearance and discontinuation of oral bile acids. A standardized questionnaire was combined with a clinical and ultrasound examination. Relief of symptoms was correlated to patient characteristics, stone volume, and gallbladder functions., Results: Twelve patients (13%) developed recurrent stones. The probability of stone recurrence was 5.5% (+/- 2.5%) after 1 yr, 12% (+/- 4.5%) after 2 yr, and 30.5% (+/- 9.5%) after 3 yr. Sixty-two of 78 stone-free patients were asymptomatic (80%). Most patients lost their typical biliary symptoms, but statistics also revealed significant differences of nonspecific symptoms and food intolerances pre- and postlithotripsy., Conclusions: This trial has confirmed that patients with symptomatic gallstone disease exhibit a wide spectrum of symptoms, many of which are relieved by ESWL. The fact that at least every fifth patient is not free of symptoms after the gallstone has been removed is in keeping with the findings after cholecystectomy. According to our data, recurrence rate after successful ESWL is higher than previously reported and similar to results after oral litholysis, with no differences between single and multiple stones.

Today, nearly 90% of common bile duct stones are extracted endoscopically. Problems are encountered if there are large stones or a duct stenosis. Extracorporeal piezoelectric lithotripsy (EPL) as well as intracorporeal electrohydraulic lithotripsy (EHL) serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. A total of 35 patients with common bile duct stones in whom conventional endoscopic treatment had failed were selected on the condition that stone visualization through ultrasound was possible and that the papilla was within easy reach of the endoscope. Patients fulfilling the inclusion criteria were randomly treated either by EPL or EHL. The average age of our patients was 73 years. The main reasons for failure of conventional endoscopy were due to the large size of the stones (13 patients), impacted stones (16), or the presence of a biliary stricture (6). In the EPL group, visualization of the stones by ultrasound and ensuing treatment were possible in 16 of 18 patients (89%); stones could be fragmented in 15 patients. In 13 patients, the biliary tree could then be completely freed of calculi; the success rate was 72% for all the patients (13 of 18). On average, the patients had 2.3 treatments on the lithotripter, and 3870 shock waves were applied per treatment. In the EHL group stones were successfully fragmented in 13 of 17 patients (76.5%). The average number of treatments was 1.4. Comparing both therapies, there was no difference in stone-free rates. In both groups, additional endoscopic interventions were necessary to clear the bile duct.(ABSTRACT TRUNCATED AT 250 WORDS)

Aim: Extracorporeal shock-wave lithotripsy (ESWL) with underwater spark discharge and stone localisation via x-ray has become established in the treatment of difficult bile duct stones. First results with the piezoelectric lithotripter (EPL) in our department have also been promising., Method: Between 1989 and 1993 we were able to treat 79 patients (mean age 76 years) with problematic bile duct stones with the EPL. Twenty-seven patients had solitary stones, 52 patients presented with multiple stones. Seventy-one patients received a nasobiliary tube to decompress the biliary system. For extracorporeal lithotripsy, we used a piezoelectric lithotripter (Piezolith 2300, R. Wolf, Knittlingen, Germany)., Results: Visualisation of the stones by ultrasound and ensuing treatment were possible in 71 out of 79 patients (90%), and complete stone removal was achieved in 62 patients (78.5%) after 7,595 shock-waves were applied per patient on average. In 55 patients, endoscopic extraction of fragments was performed to avoid fragment complications. Nearly all patients in whom extracorporeal lithotripsy failed were cleared of their stones by additional use of intracorporeal electrohydraulic lithotripsy. Three patients received palliatively an endoprosthesis and two patients were referred to surgery., Conclusion: EPL with sonographic stone localisation and mild sedo-analgesia is a valuable adjunct in the treatment of difficult biliary tract calculi. It is a worthwhile alternative especially for elderly patients who would be at high risk on general anaesthesia.

Extracorporeal shockwave lithotripsy (ESWL) is a feasible procedure for the treatment of gallbladder stones in humans. Well-selected patients can achieve stone-free rates in a high percentage. With the gallbladder in situ, these patients are at risk of stone recurrence. There is considerable evidence that aspirin prevents cholesterol gallstone formation in animal models and may prevent gallstone recurrence in man. We attempted to clarify the risk of gallstone recurrence after successful piezoelectric lithotripsy in patients taking either low-dose aspirin or no medication. The first 45 patients shown to be completely free from stones after ESWL were randomized into two groups. One group received 100 mg aspirin daily; the other group did not receive any further medical therapy. Patients were further examined on an average of 19.6 months and 21.9 months, respectively. In the aspirin group the recurrence rate was 18.2%, whereas 21.7% of the patients in the control group developed recurrent stones. Seventy-eight per cent of these patients also had a recurrence of biliary pain. By life-table analysis we had, after a follow-up period of 24 months, a stone recurrence rate of 25% (+/- 11) in the aspirin group and 34% (+/- 14) in the control group. Our results indicate that recurrence prophylaxis remains one of the central questions in ESWL. In this preliminary study, 100 mg of aspirin daily was not able to reduce the recurrence rate after successful ESWL. Further studies will have to show whether higher doses of aspirin or other ways of preventing gallstone after ESWL are possible.

With the aim of identifying the criteria that have a decisive influence on the success of treatment of gallstones with ESWL and oral dissolution therapy, we investigated, in 117 patients, the stone-free rate as a function of sex, age, weight quotient, number of stones, total stone volume, and gallbladder function. The following inclusion criteria were applied: (1) the Munich criteria, (2) a follow-up period of at least 12 months, or (3) freedom from stones irrespective of the duration of the period of follow-up. Although, owing to the small number of cases involved, no significantly differing results were seen in the parameters investigated, clear tendencies were indeed observed. While age, sex, and weight quotient appear to have no influence on the stone-free rate, the number of stones, total stone volume, and gallbladder function do appear to have an effect on the results of treatment. Patients with solitary stones not more than 20 mm in diameter, and patients with a small total stone volume and good gallbladder function would appear to have the best chance of becoming stone-free within a short period of time, irrespective of age, sex, or girth.

64 patients (27 men, 37 women; mean age 71 [27-90] years) with intra- or extrahepatic biliary stones, which could not be extracted endoscopically, underwent extracorporeal piezoelectric shock-wave lithotripsy (ESWL). The piezoelectric lithotripter which was used localizes the stones sonographically and the shock-waves are produced by a self-focusing sound generator consisting of 3,000 ceramic elements. The sonographic localization of the stones was successful in 57 patients (89%) and complete removal of stones was achieved in 49 (77%), after an average of 7,595 (1,000-30,800) shock-waves per patient. Spontaneous elimination of stone fragments occurred in 7 patients, while in 42 further endoscopic procedures (balloon catheter, Dormia basket, mechanical lithotripsy) were needed to remove stone fragments from the biliary tract. The only severe complication was cholangitis in two cases. It probably resulted from the associated lysis treatment. There was no case of pancreatitis and no death at 30 days. These data indicate that piezoelectric ESWL with sonographic stone localization is an effective method with few side effects for treating problematic biliary tract stones.

Extracorporeal shock-wave lithotripsy (ESWL) is a non-invasive technique in gallstone management, which has been in clinical use since many years now. Exact patient selection provides considerable stone-free rates within a year. Side effects and complications are rare. The stone-recurrence rate is about 15% after two years, and thus lower compared to that after oral dissolution therapy alone. Until now, there is no reasonable medical therapy to prevent stone recurrence. Furthermore, ESWL is a suitable therapy for retained common bile duct stones. Although laparoscopic cholecystectomy has become established as a new, minimally invasive surgical method, ESWL will continue to be a successful technique for the treatment of thoroughly selected gallstone patients, who are looking for a non-invasive way to get rid of their biliary pain, but not of their gall bladder.

Extracorporeal piezoelectric shock wave lithotripsy (EPL) was performed in 35 patients with endoscopically non-extractable stones. With this lithotripter, stones are visualized by ultrasound and shock waves are produced by a piezoelectric acoustic generator. The stones could be localized in 32 out of 35 patients. Fragmentation was achieved in 91.4% and complete stone removal in 77.1%. These results show that piezoelectric lithotripsy is also a useful method for the treatment of complicated bile duct stones, as already demonstrated for the electrohydraulically and electromagnetically generated shock waves systems. The piezoelectric system is especially useful in elderly and frail patients because no general anesthesia is needed and only 14% of cases require analgesia or sedation.

Intracorporeal shockwave lithotripsy was performed in 36 patients with problematic common bile duct stones. All of the patients had undergone unsuccessful mechanical lithotripsy prior to this procedure. In 29 patients (80.6%), the stones were fragmented under cholangioscopic control and subsequently extracted with a Dormia basket. In seven patients, the procedure failed due to stone impaction or failure to intubate the common bile duct with a nasobiliary tube. No complications were observed. Cholangioscopically guided intracorporeal shockwave lithotripsy is a highly effective and safe procedure for the conservative treatment of complicated common bile duct stones.

Aims: Analysis of the results of piezoelectric lithotripsy of gallstones combined with subsequent dissolution therapy using chenodeoxycholic acid and ursodeoxycholic acid., Design of Study: Retrospective evaluation after 2 1/2 years application in the department; prospective study for stone recurrence with ASA., Patients: A total of 246 patients with gallbladder stones selected on the basis of the Munich criteria; 171 patients were followed up for at least 24 months., Results: With piezoelectric shockwave lithotripsy treatment can mostly be carried out without the need for analgesia. When the indication is strictly applied, a stone-free rate of almost 90% after one year can be achieved. To achieve this, regular use of bile acids for dissolution of the fragments remaining after lithotripsy is required. At the present time, our recurrence rate is around 14% after one and two years. The use of acetylsalicylic acid recurrent stone prophylaxis was of no benefit., Conclusions: Extracorporeal shockwave lithotripsy now forms a permanent part of the conservative therapeutic approach to cholecystolithiasis. The results obtained are largely dependent upon an accurate indication. Particularly suitable patients are those with solitary cholesterol stones in a properly functioning gallbladder.

Between January and May 1989, 65 patients with symptomatic gallbladder stones were treated with extracorporeal piezoelectric lithotripsy (EPL) and supplementary dissolution therapy with oral bile acids. In 98% of the patients, fragmentation of stones was achieved. On average, each patient received 3.18 treatments. In addition to attacks of colic and asymptomatic changes in laboratory parameters, one hematoma of the gallbladder and one of the liver were observed, together with pancreatitis and cholecystitis in two patients each. During the follow-up period, three patients developed symptomatic bile duct stones. An endoscopic retrograde cholangiopancreatography (ERCP) with papillotomy was performed on four occasions, while one female patient had to undergo urgent cholecystectomy for inflammation of the gallbladder and empyema. Six months after the initial treatment, 36 (55%) patients were free of stones, while the stone-free rate after 12 months was 64.5% (41 of 65). Ninety percent of the patients with a solitary stone less than or equal to 2 cm in diameter became stonefree within a year. Extracorporeal piezoelectric lithotripsy is clearly a feasible procedure for the treatment of certain gallstone patients.

More than 90% of all common bile duct stones are today extracted endoscopically after papillotomy with the Dormia basket in combination with the mechanical lithotripter. For patients with endoscopically unremovable stones, there are now new therapies as an alternative to surgical intervention. Ductal stones can either be fragmented by extracorporeal shock wave lithotripsy or by peroral cholangioscopic guided electrohydraulic lithotripsy. The remaining fragments can then be easily extracted endoscopically. If the stone cannot be removed by using these new techniques, a palliative endoprosthesis can by implanted. We report on our experiences and results with the extracorporeal piezoelectric shock wave lithotripsy and the intracorporeal electrohydraulic therapy in 44 patients with complicated bile duct stones. Applying extracorporeal shock wave therapy, treatment was successful in 75% of the patients with common bile duct stones, intracorporeal electrohydraulic lithotripsy was successful in 71%. By combination of both techniques, the calculi could be removed in 84% of those patients where before one of both therapies had failed. Finally, the rate of success in the above mentioned 44 patients was 93%. It could be shown by this investigation that both therapeutic methods complete each other in the treatment of the complicated common bile duct stones.

Today, common bile duct stones are extracted endoscopically. After endoscopic sphincterotomy, nearly 90% of all stones can be removed with a Dormia basket or a mechanical lithotripter. Problems are encountered if there are larger stones or a duct stenosis. New conservative therapies do serve as an alternative to surgical intervention for those few patients in whom endoscopic measures have failed. Stone fragmentation can be achieved by extracorporeal shock wave lithotripsy, and remaining fragments can be removed endoscopically. So far, authors of most reports on the successful disintegration of common bile duct stones used the Dornier lithotripter. Stone localization is thus achieved with x-rays, and the shock waves are generated by an underwater spark discharge. We report on our experiences and results with extracorporeal piezoelectric shock wave lithotripsy (EPL) in 19 patients with complicated bile duct stones. With this lithotripter, stones are visualized by ultrasound, and shock waves are produced by a piezoelectric acoustic generator. Fragmentation was achieved in 84.2%, and complete stone removal in 78.9%. These results show that piezoelectric lithotripsy is also a useful method for the treatment of complicated bile duct stones, as has already been proved for the electrohydraulic- and electromagnetic-generated shock waves systems. However, the renunciation of general anesthesia and the need for analgesia or sedation in only 25% of the treatments render this lithotripter system attractive, especially for elderly and frail patients.

From January to May 1989, 50 patients with symptomatic gallstones were treated by means of extracorporeal piezoelectric lithotripsy combined with oral bile acid therapy. In 98% of all patients stone fragmentation was achieved. The mean number of treatment sessions per patients was 3.24. We observed as complications one gallbladder- and one liver hematoma each besides colicy pain and asymptomatic laboratory changes. Two patients developed mild pancreatitis and two a cholecystitis; three patients had symptomatic common bile duct stones during the follow-up. ERCP with endoscopic papillotomy was performed four times, one female patient had to undergo surgery due to an acute gallbladder. Three months after the first treatment, 18 patients (36%) were stonefree, six months later 54% (21/39). Patients with solitary stones up to 2 cm in size were in 71.5% stonefree respectively after three months. Thus, piezoelectric lithotripsy represents in our opinion a possible therapeutic modality for the treatment of symptomatic gall stones in selected patients.

Since endoscopic papillotomy and extraction of stones out of the bile duct have become established procedures, the therapeutic approach to choledochlithiasis has fundamentally changed. 80 to 90% of all stones can be extracted by this method. New techniques can be applied for larger stones or for anatomical variations of the common bile duct. Mechanical lithotripsy, a technique by which further 80 to 90% of the remaining stones can be extracted, has been perfected for clinical use. In addition, laser lithotripsy, guided by choledochoscopy, is an elegant alternative for treating large solitary concrements. Extracorporal shock wave lithotripsy, too, is a valuable technique in certain cases. Applying these new techniques has further improved therapeutic results. Despite all this progress, however, it should not be forgotten that, besides the surgical removal of bile duct stones, the condition of choledocholithiasis can, especially in old people, run a mild and uneventful course.

The "problematic common bile duct stone", which cannot be extracted primarily by routine endoscopic methods is one of the indications for extracorporeal shock wave lithotripsy (ESWL). We report on the successful piezoelectric lithotripsy of a large common bile duct stone in an 86-year-old patient. Focusing was achieved by ultrasound without problems; the resulting fragments were extracted endoscopically without difficulty. No side effects were observed in this painless piezoelectric lithotripsy.