The place of lithotripsy and surgery in the management of gallstone disease.

In summary, 10% to 20% of all symptomatic and uncomplicated gallbladder stones can be treated by ESWL under the current entry criteria. Further, ESWL is suitable for patients with bile duct stones in whom the primary endoscopic approach is not successful (about 10%). The algorithm in Figure 7 shows the therapeutic modalities that may be employed if the least invasive therapy is chosen. The different methods shown in this diagram are usually carried out by different specialists including surgeons, gastroenterologists, or radiologists. Therefore, an interdisciplinary approach is desirable. The technology of shock wave therapy of gallbladder stones will be improved in the future, for example the efficacy of stone fragmentation while maintaining a low level of discomfort for the patient. Moreover, repeated shock wave treatments may increase the success rate in patients with multiple stones and possibly in those with slightly calcified stones as well. Repeated procedures for recurrent stones appear feasible. Long-term follow-up studies are needed to define the place of ESWL in the management of gallstone disease. Surgery of the gallbladder remains the "gold standard" of curative therapy of gallbladder stones, against which ESWL and other nonsurgical techniques have to be evaluated. For the therapy of bile duct stones, ESWL is a helpful and effective nonsurgical adjunct.