Trends in the treatment of gallstone disease: putting the options into context

The new nonsurgical methods of treating gallstone disease rely on fragmentation, such as with extracorporeal shock-wave lithotripsy (ESWL), or dissolution, such as with ursodiol. Fragmentation alone is usually insufficient for gallbladder stones, and dissolution is only possible for cholesterol stones. Although oral dissolution with or without ESWL is an attractive alternative to surgery, only 25 percent of patients are candidates for this therapy. Dissolution of gallbladder stones by topical application of methyl tert-butyl ether (MTBE) is another option whose safety is still open to question. Therefore, cholecystectomy will remain the principal treatment for symptomatic gallbladder stones. Common duct stones can be eliminated in 90 percent of cases by endoscopic sphincterotomy alone, and fragmentation of large common duct stones by mechanical endoscopic lithotripsy or ESWL can bring the success rate up to about 95 percent. Unless cholecystectomy is also required, surgery will have a secondary role in the treatment of common duct stones.