J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from New Trends In The Treatment Of Calculus Disease Of The Biliary Tract Phillip Price, MD, and Thomas H. Hartranft, MD

Background: New treatment methods for calculus disease of the biliary tract offer options that can benefit a variety of patients. Laparoscopic surgery, for example, has revolutionized biliary surgery and is now the preferred approach for the majority of patients. Methods: Using the key words "biliary tract," "calculus disease," and "cholecystectomy," MEDLINE files were searched from 1982 to the present. Articles dating before 1982 were accessed from the reference lists of the more recent articles. Results and Conclusions: This review describes the various procedures that could be effective options for patients with biliary stone disease, including an algorithm showing a proposed scheme for evaluating and treating this disease. Cholecystectomy - either laparoscopic or open - will likely remain the treatment of choice for most patients. The newer options, however, for treatment of both acute and chronic cholecystitis have proved effective in select cases. (J Am Board Fam Pract 1995; 8:22-8.)

The treatment of patients with calculus disease of of interest has been directed toward the develop­ the biliary tract has changed dramatically during ment of new treatment methods. the past 20 years. Today a variety of new tech­ Approximately 80 percent of biliary tract niques offer effective and safe treatment for pa­ stones are composed of cholesterol. Many factors tients with biliary stone disease. Although sur­ predispose patients to the development of biliary gery will likely remain the best option for the calculi. Female sex, obesity, the use of oral con­ majority of patients, physicians and surgeons traceptives, multiparity, anticholesterol-lowering should be aware of the other options so they can drugs, and hypercholesterolemia have been carefully select the treatment that will best suit linked to the development of biliary calculi. In each patient's needs. addition, diseases of the terminal ileum - whether an inflammatory disease or a disease re­

Methods sulting in resection of that part of the intestine­ http://www.jabfm.org/ Using the key words "biliary tract," "calculus dis- can predispose a patient to the development of ease," and "cholecystectomy," MEDLlNE files cholesterol gallstones. were searched from 1982 to the present. Articles The development of the less common pig­ dating before 1982 were accessed from the refer­ mented gallstones has been linked to cirrhosis of ence lists of the more recent articles. the liver, congenital anomalies of the biliary tract, and hemolytic disease, possibly because of a pri­ on 30 September 2021 by guest. Protected copyright. Results mary hereditary deficit, such as spherocytosis, or Gallstones are a frequently occurring medical an acquired condition, such as replacement of a problem affecting approximately 10 percent of heart valve. men and 20 percent of women older than 55 Cholecystectomy is the reference standard for years of age in the United States. l It is estimated treatment of calculus disease of the biliary tract. that 20 million Americans currently have gall­ An estimated 500,000 cholecystectomies are per­ stones and that 1 million additional cases are di­ formed each year, making cholecystectomy the agnosed each year. Understandably, a great deal second most common abdominal operation, fol­ lowing Cesarean section. The procedure is safe and effective and is associated with a very low in­ Submitted, revised, 16 August 1994. cidence of morbidity and mortal~ty. The overall From the Department of Surgery, Mount Carmel Medical incidence of mortality ranges between 0.5 per­ Center, Columbus, Ohio. Address reprint requests to Thomas cent and 1.5 percent, and the morbidity ranges H. Hartranft, MD, Surgical Residency Program, Mount Carmel Medical Center, 793 W. State Street, Columbus, OH 43222. from 3.? percent to 6.9 percent. The incidence of

22 JABFP Jan.-Feb.1995 Vol. 8 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from both morbidity and mortality has declined during Oral Dissolution with Bile Acids the past 25 years. Oral dissolution of biliary calculi is performed There are several published series with mor­ with chenodeoxycholic and ursodeoxycholic acids bidity rates of less than 3 percent. Gilliland and (ActigaU, Ciba-Geigy). First performed in 1937, Travers02 reported a series of 671 elective chole­ this technique gained popularity in the 1970s and cystectomies with a 0 percent mortality rate and a 1980s. There are several reports of results 3.9 percent morbidity rate. Ganey, et a1.3 reported achieved with chenodeoxycholic acid, most no­ a 0 percent mortality rate and a 3.9 percent mor­ tably, the National Cooperative Gallstone Study.4 bidity rate in a series of 1035 patients who under­ Both drugs are now available, with Actigall being went elective cholecystectomy. the most recent. Reports of the effectiveness of cholecystectomy Bile is composed mostly of water, along with vary widely. In cases in which the disease can be at­ conjugated bilirubin, organic and inorganic ions, tributed directly to the biliary tract - such as acute small amounts of protein, and three lipids (bile cholecystitis, gallstone pancreatitis, cholangitis, salts, cholesterol, and lecithin). \Vhen the per­ biliary colic, and gallstone ileus - surgery is very centage of bile acids and lecithin is adequate, cho­ effective. In patients with less specific symptoms, . lesterol will remain in solution. Bile acids keep such as dyspepsia, flatulence, bloating, fatty food in­ cholesterol in solution by forming a micelle. Cho­ tolerance, or nonlocalized pain, the efficacy could lesterol is kept in suspension by the bile salts and be much lower, probably because the surgery is the lecithin. \Vhen the amount of cholesterol in sometimes performed to alleviate symptoms unre­ bile exceeds the capacity of the micelle to keep it lated to the biliary tract. For example, a condition in solution, however, the cholesterol precipitates that has been described as post-cholecystectomy out, and there is a chance for the formation of syndrome probably does not exist and most likely cholesterol gallstones. occurs because the initial symptoms are related to At some point during the day the vast majority other gastrointestinal problems rather than prob­ of persons have bile that is supersaturated with lems directly associated with the biliary tract. Thus, cholesterol. Nevertheless, most persons do not proper patient screening and careful selection are form gallstones, suggesting that other factors, necessary to optimize the efficacy of this procedure. which are not completely understood, contribute The main advantages of cholecystectomy are to the formation of gallstones. These factors can that it is highly effective in not only relieving include (1) defective biliary secretion (vesicles symptoms but also halting the progression of cal­ with excess cholesterol, defective bile acid flow, http://www.jabfm.org/ culus biliary tract disease, as the calculi and the deficient bile flow); (2) a rapid nucleating factor primary site of their formation are removed. In that begins the precipitation of these cholesterol most cases cholecystectomy can be performed stones (calcium has been implicated); and (3) a with minimal risk to the patient, no long-term diseased gallbladder, either because of some ab­ follow-up treatment is required, and no long­ normality in the mucosa of the organ or because term adverse effects have been documented. The of poor contractility. on 30 September 2021 by guest. Protected copyright. primary disadvantage of this procedure is that it is The primary effect of bile acids is to decrease a major, intra-abdominal procedure requiring the amount of cholesterol that is secreted into the several weeks of recovery. bile. Ursodeoxycholic and chenodeoxycholic For any new treatment to become accepted, its acids both reduce the amount of cholesterol in efficacy and safety must be compared with those the bile by blocking the action of the HMG-co­ of the reference standard treatment, in this case, enzyme-A-reductase, which controls cholesterol cholecystectomy. The new treatments are usually formation. Also, it has been proposed that ur­ performed on carefully selected patients who are sodeoxycholic acid plays a role in stopping the otherwise healthy. Because the sickest patients transport of cholesterol from within the hepato­ (who will have the worst outcomes) will not be cytes to the bile. Once bile has micelles that are candidates for these new treatment methods, the not saturated with cholesterol, those micelles are results of cholecystectomy and those of the new able to act at the bile-stone interface, slowly re­ treatments must be compared carefully to avoid move small particles of cholesterol from the drawing incorrect conclusions. stone, and, during months to years, dissolve it

Biliary Tract Calculi 23 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from into small particles. Ursodeoxycholic acid has an­ Study in Canada reported a 10.9 percent dissolu­ other effect. There is a poorly understood liquid tion rate.8 It is now realized that suboptimal doses crystalline phase that causes removal of choles­ were administered (8 mglkg/d to 10 mglkg/d). At terol from stones to the bile, where it can he the optimal dose (15 mglkg/d for chenodeoxy­ removed. cholic acid and 8.5 mglkg/d for ursodeoxycholic Because these agents have slightly different ac­ acid), an overall dissolution rate of 15 percent to tions, it has been proposed that using them 20 percent could be achieved. together might have some type of synergistic These studies found a subgroup of patients effect. This view is held by German investigators, with a high (greater than 50 percent) chance of although it is not practiced routinely in the having their gallstones dissolved in 1 to 3 years. United States. Such patients can be characterized as female, at or U rsodeoxycholic and chenodeoxycholic acids below ideal body weight, who have gallstones that have been shown to be equally effective in dissolv­ are smaller than 2 cm in diameter, radiolucent, ing cholesterol gallstones; however, the side ef­ and shown to be floating by oral cholecystogram, fects associated with chenodeoxycholic acid have thus indicating that the stones have a cholesterol often required discontinuation of treatment. Pa­ content of more than 80 percent. tients receiving therapeutic doses of chenodeoxy­ Because these oral agents are effective only on cholic acid often experience severe diarrhea. In cholesterol stones, the higher the cholesterol· addition, chenodeoxycholic acid causes elevations content, the higher the chance for dissolution. In of liver enzymes, specifically the transaminases, addition, patients with a serum cholesterol above which cause as many as one-third of the patients 227 mg/dL also have a greater chance of dissolu­ to discontinue treatment. Ursodeoxycholic acid, tion with these oral agents. while having the same efficacy, does not have the The advantage of oral dissolution with bile same side effects. There is no documentation of acids is that it avoids an abdominal surgical pro­ liver enzyme elevation, and there is only a 5 per­ cedure, and no recovery time is required. The cent incidence of clinically important diarrhea, chief disadvantage of this medical therapy is that rarely leading to discontinuation of treatment.S-7 approximately one-half the patients will experi­ Another side effect of chenodeoxycholic acid is ence a recurrence within the first 5 years. After that it tends to raise the level of low-density lipo­ 5 years the incidence of recurrence decreases protein cholesterol, known to be atherogenic. and becomes rare. Another disadvantage is that This side effect is not associated with ursodeoxy­ medications must be taken for a long time tohttp://www.jabfm.org/ choHc acid. dissolve the stones. Chances for biliary compli­ Approximately 20 percent to 30 percent of the cations developing during treatment remain patients who have gallstones meet the following unchanged. criteria for bile acid treatment: Direct Contact Dissolution

1. They have chronic cholecystitis Gallstones can be dissolved by the direct infusion on 30 September 2021 by guest. Protected copyright. 2. They have cholesterol gallstones (hile acids of monooctanoin or methyl-tertiary-butyl-ether have no effect on pigmented or calcified gall­ (MTBE) into the gallbladder or common bile stones) . duct. Monooctanoin, which will dissolve only 3. They have a functioning gallbladder, so the cholesterol gallstones, was first used in 1978 to bile acids can gain access to the stones dissolve stones in the common bile duct. This 4. Their stones are less than 1.5 to 2.0 cm in di­ treatment is effective approximately 50 percent of ameter the time. Side effects, which include primarily ab­ S. Their stones are radiolucent dominal pain, nausea, and vomiting, can result in 6. They are not pregnant and have no renal or the discontinuation of treatment in approximately hepatic disease 10 percent of the patients. This solvent can be in­ stilled into the gallbladder or common bile duct Using chenodeoxycholic acid, The National Co­ by a variety of routes: a T-tube left in place after operative Gallstone Study reported a 13.5 percent common bile duct exploration where a retained overall dissolution rate,4 and the Sunnybrook stone pas been found, a cholecystectomy tube, a

24 JABFP Jan.-Feb.1995 Vol. 8 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from transhepatic catheter, or a nasobiliary tube. This Percutaneous Drainage slow-acting agent requires an average of 5 days to This procedure is relatively new and useful for dissolve a 1- to 2 -cm cholesterol stone. patients with acute cholecystitis who are at high MTBE was first used in 1985. As will mono­ risk for a surgical procedure. The ideal patient octanoin, it wiIl dissolve only cholesterol stones. can be characterized as a patient in the intensive The toxic side effects of this agent prohibit its use care unit who might be intubated, who has multi­ in the common bile duct, because the agent will ple injuries, and who develops acute cholecystitis. overflow into the duodenum and cause anes­ The gallbladder is located using sonography, a thesia, hemorrhage, and, if it enters the vascular needle is placed percutaneously, and a drainage system, massive intravascular hemolysis with as­ catheter is inserted. In effect, this procedure can sociated renal failure. This sequence of events has be compared with draining an abscess. The ·gall­ been documented in experimental models, but we bladder can then be removed when the patient's are not aware of it occurring in humans. The ad­ condition improves. vantage of MTBE is that it acts rapidly, dissolving some stones in a few hours and most stones within Percutaneous CholecystoUthotomy 12 to 14 hours. There are very few stones that Percutaneous cholecystolithotomy is an extension cannot be dissolved in 24 hours if they are com­ of percutaneous drainage. After the tract is estab­ posed primarily of cholesterol. lished in the same manner as with percutaneous . Direct contact dissolution is effective in pa­ drainage, the tract is dilated and an operating tients who have chronic cholecystitis, a function­ scope is inserted. The stones can then be removed ing gallbladder, radiolucent cholesterol stones through the scope. Stones too large can be frag­ (any size or number), and a patent cystic duct to mented by ultrasonic beams (intra corporeal allow any remaining fragments to pass out of the lithotripsy) or by a contact laser. The advantage gallbladder. Contraindications to this procedure of percutaneous cholecystolithotomy is that it is are coagulopathy, pancreatitis, or pregnancy. To effective with all types of stones, the hospital stay perform direct contact dissolution, the gallblad­ and recovery period are shortened because only a der is first located using sonography, and a cath­ small incision is required, and no long-term treat­ eter is placed percutaneously, transhepatically ment is required. The patient must be anes­ into the gallbladder. Approximately 3 to 5 mL of thetized, however, and the procedure is invasive MTBE is injected and withdrawn from the gall­ (although minimally, when compared with a bladder every 5 minutes until the stones are dis­ standard cholecystectomy). Because the gallblad­ http://www.jabfm.org/ solved. Dissolution of the stones is monitored der is not removed, the stones will recur in ap­ either fluoroscopically by injecting contrast medi­ proximately 50 percent of the patients. um into the gallbladder or by sonography. The primary disadvantage of this direct contact disso­ Lnparoscoplc Cholecystectomy lution is that it requires the uninterrupted time of Cholecystectomy is the reference standard for treatment of gallbladder disease, and laparoscopic a physician for a period of hours to inject and on 30 September 2021 by guest. Protected copyright. withdraw the agent. A mechanical exchange unit cholecystectomy is an alternative method of ac­ is under development, but its cost is expected to complishing the procedure. The procedure is un­ be high. changed in that the gallbladder is removed; how­ The advantages of direct contact dissolution ever, laparoscopic access to the abdominal cavity include avoiding open abdominal surgery and reduces postoperative pain and recovery time. minimal recovery time. This procedure is inva­ The earliest literature reports on laparoscopic sive, however, and there is potential for serious cholecystectomy appeared in 1989, and since that complications, especially with MTBE. With time the procedure has grown in a manner un­ monooctanoin, treatment can be prolonged. Fur­ equaled in surgical history.9,lO The procedure is thermore, as with all treatments in which the gall­ carried out by viewing the gallbladder through a bladder remains in situ, there is approximately a high-resolution video camera placed through the 50 percent chance of recurrence of the stones. umbilicus. Operating ports are placed beneath The long-term effectiveness of this treatment re­ the xiphoid and costal margin, and the gallbladder mains to be determined. is removed as in the open procedure using laparo-

Biliary Tract Calculi 25 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from scopic instrumentation. The angle viewed by the (water immersion or dry methods), and a method operating surgeon is different, and a two-dimen­ of imaging the stone (sonography or fluoroscopy). sional rather than three-dimensional view is ob­ Coupling can be achieved by water immersion tained. These factors, together with the addi­ or by dry methods. Water immersion is cumber­ tionallaparoscopic instrumentation, require a some, because large amounts of water have to be period of relearning before the procedure can be prepared for each treatment, and if an emergency carried out safely. occurred during treatment, rapid access to the pa­ It has been proved that laparoscopic cholecys­ tient is difficult. Most lithotripters today use the tectomy is a safe and effective treatment for dry method, which involves applying a mineral oil cholelithiasis,11 although there is a higher inci­ barrier to the skin. Sonographic imaging is most dence of common duct injury.12 It is likely that effective for biliary lithotripsy, whereas fluoro­ mortality and morbidity will decrease as surgical scopic imaging is most effective in locating com-· experience is gained with the technique. mon bile duct stones. The National Institutes of Health recently ap­ To be eligible for biliary lithotripsy, patients proved laparoscopic cholecystectomy as a safe and must have from one to three gallstones, 5 mm to effective technique for the treatment of gallblad­ 30 mm in diameter, a functioning gallbladder as der disease. Laparoscopic cholecystectomy is the demonstrated by oral cholecystogram, no calci­ procedure of choice for patients with chronic fied stones, and only minor medical problems. cholecystitis at this time and, with increasing With these criteria, approximately 10 percent to experience, will undoubtedly be used for the 20 ~erc:nt of gallstone patients are eligible. The treatment of acute cholecystitis with increasing patient IS sedated for the procedure, the stone is frequency. located using sonography, the computer directs Of all the techniques described, laparoscopic the focusing, the shock waves are generated, cholecystectomy is the most widely applicable a~d the stones are fragmented. Although litho­ and once again firmly establishes surgery as the tnpsy does not fragment the stones into pieces primary treatment for calculus biliary tract dis­ small enough to pass from the gallbladder spon­ ease. All types of stones can be treated, and gall­ taneously, it fragments them into smaller stones bladder function does not affect the ability to so there is a larger surface area allowing the carry out the procedure. Hospital stay is usually stones to be dissolved more rapidly with ursode­ less than 24 hours, and patients can return to nor­

oxycholic acid, which is the final part of the http://www.jabfm.org/ mal activities in 3 to 4 days. treatment. Sackmann, et al. l3 reported the landmark Extracorporeal Shock Wave Lithotripsy study of the first 175 patients treated in this Pioneered by West German researchers for the manner. The majority of patients had solitary treatment of renal calculi, lithotripsy was devel­ stones smaller than 2 cm in diameter. Overall, 30 oped in 1960, and actual clinical studies were un­ percent of the patients were stone-free 2 months dertaken in 1974. Biliary lithotripsy experimenta­ following the procedure, 48 percent at 4 months, on 30 September 2021 by guest. Protected copyright. tion began in 1976 with clinical trials beginning 63 percent at 8 months, and 91 percent at 18 in the mid-1980s. months. For the patients with solitary stones The principle of lithotripsy can be described smaller than 2 cm in diameter, success was im­ as follows: (1) An explosive force is followed by proved, with the corresponding values of 45 per­ (2) an expansion of gaseous elements, generating cent, 69 percent, 78 percent, and 95 percent, re­ (3) a high-velocity shock wave, which is followed spectively. The treatment was less effective in by (4) transmission of this shock wave to the those patients with large (larger than 2 cm) or patient, resulting in (5) an impact on variable den­ multiple stones. sity (the stones). To date there have been no serious or life­ The elements of the lithotripter are an energy threatening complications associated with this source (either spark cap, electromagnetic, piezo­ treatment. Approximately 30 pe:.:cent to 50 per­ electric ceramic, or microexplosive), a focusing cent of patients will continue to have biliary colic, device (to focus the shock wave on the stone), a however, and 25 percent will have skin ecchy­ method of coupling the patient to the shock wave mosis; ~ransient nausea and vomiting and gross

26 JABFP Jan.-Feb.1995 Vol. 8 No.1 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from hematuria have also been reported. Currently bil­ acute cholecystitis. The treatment options avail­ iary lithotripsy is an experimental treatment with able for chronic and acute cholecystitis can be final Food and Drug Administration approval summarized as follows: pending. For the 10 percent to 20 percent of eligible Acute Cholecystitis patients, biliary lithotripsy eliminates the pain For patients with acute cholecystitis, primary and risk of surgery, can be performed as an out­ cholecystectomy, either laparoscopic or conven­ patient procedure, and minimizes recovery tional open, is the treatment of choice. Patients time. The disadvantages are that long-term who are considered to be at high-risk for an intra­ medical dissolution is required, some patients abdominal surgical procedure can now be treated require re-treatment with the lithotripsy, and with percutaneous drainage if medical treatment there is the same chance of stone recurrence is not successful. If percutaneous drainage is un­ found with other medical treatments (50 per­ successful, traditional cholecystectomy can then cent at 5 years). be performed.

Summary of Treatment Options Chronk Cholecystitis Figure 1 diagrams a suggested treatment scheme For patients with chronic cholecystitis, the stones encompassing all new treatment modalities. Pa­ must be characterized by type and number, and tients with biliary calculi can be divided into two gallbladder function must be assessed before basic categories: those with chronic or those with treatment options can be determined.

TREATMENT APPROACH TO CALCULUS DISEASE OF THE BILIARY TRACT

Biliary Tract Stones I Tx Chronic Cho/ecystitiiS.S _____..L _____ Acute ChOleCystiliT Open Cholecystectomy CholesteroL I Pigmented Stones Stones '4 - .. Stones Calcified on Flat Plate t Continued ~ Tx • High Surgicat Risk Deterioration Open or laparoscopic Cholecystectomy

Evaluate Stone Load laparoscopic Cholecystectomy L http://www.jabfm.org/ I PCCL ~~rcutaneous Drainage J o;;Three Stones > Three Stones + orSolitary !1------...... TxOpen or laparoscopic Cholecystectomy OCG >3cmStone Stone laparoscopic Cholecystectomy ~ .. High Surgical Risk .I

+ on 30 September 2021 by guest. Protected copyright. Functioning GB -""""" GB I C_.GB ~en~r laparoscopic Cholecystectomy Functioning GB -. ~~BE laparoscopic Cholecystectomy peCl

Small Floating Stone by OCG Larger Non-Floating Stones by OCG

Tx + Tx + Bile Salts (Best Chance Success) ESWl (Without Other Exclusionary Criteria) ESWl (Without Other Exclusionary Crneria) Open or laparoscopic Cholecystectomy Open or laparoscopic Cholecystectomy PCCl PCCL MTBE (High Risk) MTBE (High Risk)

Figure 1. Treatment approacb to calculus disease of the biliary tract. GB =gallbladder, Tx =treatment, Peel =percutaneous cholec:ystolithotomy, MTBE =methyl-tertiary-butyl-ether, ESWL =extracorporeal shock wave lithotripsy, OCG =oral cholecystogram.

Biliary Tract Calculi 27 J Am Board Fam Pract: first published as 10.3122/jabfm.8.1.22 on 1 January 1995. Downloaded from

Cholesterol Stones 2. Gilliland TM, Traverso LW. Modern standards for Because 80 percent of all gallstones are choles­ comparison of cholecystectomy with alternative terol stones, a wide variety of options are avail­ treatments for symptomatic cholelithiasis with able. If there are more than three stones or a soli­ emphasis on long-term relief of symptoms. Surg Gynecol Obstet 1990; 170(1):39-44. tary stone larger than 3 cm in diameter, the first 3. Ganey ]B, Johnson PA]r, Prillaman PE, McSwain treatment choice will be one of the surgical pro­ GR. Cholecystectomy: clinical experience with a cedures (open or laparoscopic cholecystectomy or large series. Am] Surg 1986; 151:352-7. percutaneous cholecystolithotomy). If the patient 4. Schoenfield L], Lachin]M. Chenodiol (chenodeoxy­ is at high risk for surgery, however, and oral cholic acid) for dissolution of gallstones: the National cholecystogram shows that the gallbladder is Cooperative Gallstone Study. A controlled trial of ef­ ficacy and safety. Ann Intern Med 1981; 95:257-82. functioning, the patient will be a candidate for 5. Fromm H, Roat]W, Gonzalez V, Sarva RP, Farivar MTBE treatment, because the stone load has no S. Comparative efficacy and side effects of ursode­ effect and the only requirement is that the stones oxycholic and chenodeoxycholic acids in dissolving are cholesterol gallstones. If the gallbladder gallstones. A double-blind controlled study. Gastro­ is not functioning, however, the patient must enterology 1983; 85:1257-64. be treated with one of the surgical options. If 6. ~achrach WH, Hofmann AF. Ursodeoxycholic acid m the treatment of cholesterol cholelithiasis. Part r. there are fewer than three stones and an oral Dig Dis Sci 1982; 27:737-61. cholecystogram shows a functioning gallbladder, 7. Idem. Ursodeoxycholic acid in the treatment of cho­ the patient is eligible for all three treatments, and lesterol cholelithiasis. Part II. Dig Dis Sci 1982; the choice is best determined by the patient and 27:833-56. the physician. 8. Fisher MM, Roberts EA, Rosen IE Shapero TF. Sutherland LR, Davies RS, et al. The Sunnybrook For patients with larger, nonfloating stones, Gallstone Study: a double-blind controlled trial of treatment options consist of extracorporeal shock chenodeoxycholic acid for gallstone dissolution. wave lithotripsy, cholecystectomy (open or laparo­ Hepatology 1985; 5:102-7. scopic), percutaneous cholecystolithotomy, or 9. Dubois F, Icard P, Berthelot G, Levard H. Coelio­ MTBE for patients who are at high risk for sur­ scopic cholecystectomy. Preliminary report of 36 cases. Ann Surg 1990; 211(1):60-2. http://www.jabfm.org/ gery. For patients with nonfunctioning gallblad­ 10. Reddick E], Olsen DO, Daniell ]F, Saye WB, ders, one of the three forms of cholecystectomy McKernan B, Miller W. Laparoscopic laser chole­ should be used. cystectomy. Laser Medicine and Surgery News and Advances 1989; 7:38-40. Noncholesterol Stones 11. Cuschieri A, Dubois F, Mouiel], Mouret P, Becker H, Buess G, et al. The European experience with For patients with pigmented or calcified stones, laparoscopic cholecystectomy. Am] Surg 1991; one of the three surgical options must be used: (1) 161:385-87. on 30 September 2021 by guest. Protected copyright. open cholecystectomy, (2) laparoscopic cholecys­ 12. Peters ]H, Gibbons GD, Innes ]T, Nichols KE, tectomy, or (3) percutaneous cholecystolithotomy. Front ME, Roby SR, et al. Complications of laparo­ scopic cholecystectomy. Surgery 1991; 110:769-78. 13. Sackmann MS, Delius M, Sauerbruch T, Holl], References Weber W, Ippisch E, et al. Shock-wave lithotripsy of 1. Kern F Jr. Epidemiology and natural history of gall­ gallbladder stones. The first 175 patients. N Engl] stones. Semin Liver Dis 1983; 3(2):87-96. Med 1988; 318:393-97.