The role of extracorporeal shock wave lithotripsy in the treatment of chronic pancreatitis.

Pain is the most frequent symptom in chronic pancreatitis (CP) and has an important impact on quality of life. One of its major pathophysiological mechanisms is ductal hypertension, caused by main pancreatic duct stones and/or strictures. In this article, we focus on extracorporeal shock wave lithotripsy (ESWL) as a treatment for main pancreatic duct stones, which have been reported in >50% of CP patients. ESWL uses acoustic pulses to generate compressive stress on the stones, resulting in their gradual fragmentation. In patients with radiopaque obstructive main pancreatic duct (MPD) stones larger than 5 mm, located in the pancreas head or body, ESWL improves ductal clearance, thereby relieving pain and improving quality of life. In case of insufficient ductal clearance or the presence of an MPD stricture, ESWL can be followed by endoscopic retrograde cholangiopancreatography (ERCP) to increase success rate. Alternatively, direct pancreaticoscopy with intracorporeal lithotripsy or surgery can be performed.

Oral Litholysis in Patients with Chronic Calcific Pancreatitis Unresponsive to or Ineligible for Extracorporeal Shock Wave Lithotripsy and Endoscopic Therapy.

BACKGROUND/AIMS: Our study aimed to evaluate the effect of oral litholysis in patients with chronic calcific pancreatitis (CCP) unresponsive to or ineligible for extracorporeal shock wave lithotripsy (ESWL) and endoscopic therapy. METHODS: Trimethadione, an antiepileptic agent, was administered orally at a dose of 0.6-0.9 g/day to 15 patients with this condition. Treatment outcome was evaluated by assessment of dissolution of the pancreatic stones on plain X-ray films and computed tomography scans of the upper abdomen. Plasma glucose, hemoglobin A1c, and body mass index (BMI) were also monitored throughout the therapy. RESULTS: Litholysis was observed in 13 out of 15 patients (86.7%) and was definite in 10 and partial in 3. Six patients had pancreatitis attacks during the therapy; 5 of whom showed definite litholysis and had only 1 mild attack. Of the 11 patients with normal or impaired glucose tolerance at baseline, none developed diabetes mellitus and all showed litholysis. BMI significantly increased in patients whose pancreatic stones dissolved. There was no vital organ impairment by trimethadione. CONCLUSION: Oral litholysis using trimethadione may represent a noninvasive and effective complementary treatment in patients with CCP unresponsive to or ineligible for ESWL and endoscopic therapy.

Extracorporeal shock wave lithotripsy 25 years later: complications and their prevention.

OBJECTIVE: We review the pathophysiology and possible prevention measures of complications after extracorporeal shock wave lithotripsy (ESWL). METHODS: A literature search was performed with the Medline database on ESWL between 1980 and 2004. RESULTS: ESWL application has been intuitively connected to complications. These are related mostly to residual stone fragments, infections, and effects on tissues such as urinary, gastrointestinal, cardiovascular, genital, and reproductive systems. Recognition of ESWL limitations, use of alternative therapies, correction of pre-existing renal or systemic disease, treatment of urinary tract infection, use of prophylactic antibiotics, and improvement of ESWL efficacy are the most important measures of prevention. Decrease of shock wave number, rate and energy, use of two shock-wave tubes simultaneously, and delivery of two shock waves at carefully timed close intervals improve ESWL efficacy and safety. CONCLUSION: ESWL is a safe method to treat stones when proper indications are followed. The need for well-designed prospective randomised trials on aetiology and prevention of its complications arises through the literature review.

[Prostatic calculi: diagnostic and therapeutic aspects]. / Osobennosti diagnostiki i lecheniia kamnei predstatel'noi zhelezy.

Strength properties of prostatic calculi (PC) were studied by microhardness HV. Fifteen calculi under study were divided into 3 groups by the size: 2-3 mm (group 1), 4-6 mm (group 2), > 6 mm (group 3). The surface of the thin sections of the calculi appeared as concentric, spherical layers of different size indicating formation of the calculus from the center. In the latter one could see a pigmented nucleus of organic nature. Some calculi had two nuclei under one cover--attached calculi. Correlations between the structure, morphology of prostatic calculi and their strength properties were established. These correlations allowed one to characterize destruction features of the calculi in different destructing impacts. We have designed and introduced into practice a complex of local physiotherapy in prostatolithiasis. This physiotherapy was conducted in combination with medicines for chronic prostatitis and included exposure of the prostate to ultrasound in impulse regime (4 mc, 0.4-1.0 W/cm2). The ultrasound was delivered through the rectum (insertion of the setting IUT 2.264-7-2.09u to the site of the concrements location) and alternated with laser therapy (insertion of the radiator P-2 into the rectum and radiator LO1 to the perineal area (5 W, 80 Hz, 64-128 s) and introduction of sulfide mud heated with the device PPK-01 Pra, electrostimulation for better passage of the prostatic section. The above therapy destructed the concrements which eliminated from the prostatic ducts as a result of which prostatic function recovered. The complex produced a good effect: 65% patients stated enhancement of the erectile function after 3 days of the treatment. After 5-6 procedures pain syndrome relieved in 40% patients, after 11-15 procedures in 87%. Ultrasonic investigation showed that posttreatment size of the prostate diminished from 0.8 to 0.2 cm. The absence of the calcinates's shadows were recorded in 87% patients, the symptoms of chronic prostatitis disappeared. The results of the combined physiotherapy demonstrate efficacy of the above method in true prostatoliths.

In vitro effect of hyperbaric oxygen on the chemolysis of infective stones.

BACKGROUND: In order to extend the feasibility of hyperbaric oxygen therapy in the urological field, the present study aimed to investigate the dissolution activity of human infective stones in UROCITRA solution under hyperbaric oxygen condition. METHODS: The dissolution activity of 7 struvite and 11 mixed struvite and carbonate apatite stones in UROCITRA solution were studied under 2.5 atmosphere (atm) hyperbaric oxygen (HBO) status in a Sigma I N-124 monoplace chamber. Another 7 struvite and 10 mixed struvite and carbonate apatite stones were also studied under normal condition. Chemolysis was performed in a drip device with a 150-ml/hour continuous flow rate. RESULTS: Under 2.5 atm HBO status, the PO2 of UROCITRA solution was 365 +/- 44 mmHg, which was significantly higher than that of tap water (113 +/- 62 mmHg) and UROCITRA solution (125 +/- 12 mmHg) under normobaric condition (p < 0.001). The decreases in the stone weight of struvite under normobaric condition were 31 +/- 8.8% after 2 h and 48 +/- 15% after 4 h of treatment. The HBO-enriched UROCITRA solution did not increase the dissolution activity as reflected by comparable decreases in the dried stone weight (31.2 +/- 14.6% and 54 +/- 19% at the 2nd and 4th post-treatment hours, respectively, p > 0.05). Similarly, there was no significant difference in the percent stone weight decrease of the mixed struvite and carbonate apatite stones under either HBO or normobaric condition. The dissolution responsiveness of struvite was significantly greater than that of the mixed struvite and carbonate apatite stones. CONCLUSIONS: The chemolysis of struvite in UROCITRA solution is significantly greater than that of the mixed struvite and carbonate apatite stones. However, the UROCITRA solution enriched with HBO does not enhance the dissolution of infective stones.

Experimental dissolution of pigment gallstone material using alkaline EDTA and adjuvant bile salts/non-bile salt detergents, thiols and urea, with respect to local chemolitholysis.

In order to enhance the dissolution capacity and the kinetics of topical solvents used in local pigment chemolitholysis, a series of dissolution experiments was performed with intact brown and black pigment stones and with standardized solutes such as pigment stone powder and compressed powder (static disc method). The basic dissolution medium was a 0.1 M boric acid/sodium carbonate buffer (pH 9.5), and the basic lytic agent was EDTA-4Na, working satisfactorily at 1-3 g/dl. It could be demonstrated that the dissolution efficiency of this basic solvent was enhanced significantly in the presence of a detergent (surfacant) and of urea. Among the detergents the zwitterionic (e.g., Sulfobetain-12) and the nonionic types (e.g., a polyoxyethylene ether like Lubrol PX) proved to be most effective. The adjuvant effect of the investigated thiols was disappointing. Only dithioerythritol/dithiothreitol and N-acetylcysteine showed any moderate, if consistent, lytic activity. The highest dissolution rates in dissolving compressed powder standards (disc method) were achieved with the ternary solvent (1% w/v EDTA/80 mM Lubrol PX/1 M urea, pH 9.5). Intact black pigment stones, well known as problematic candidates for chemolitholysis, could be largely dissolved up to approximately 70% of their initial weight. This was not merely a physical disintegration, but a chemical process.