Current issues of ACP Journal Club are published in Annals of Internal Medicine


Inpatient piezoelectric extracorporeal shock-wave lithotripsy cost more than open cholecystectomy for symptomatic patients

ACP J Club. 1993 Mar-April;118:60. doi:10.7326/ACPJC-1993-118-2-060

Source Citation

Nicholl JP, Brazier JE, Milner PC, et al. Randomised controlled trial of cost-effectiveness of lithotripsy and open cholecystectomy as treatments for gallbladder stones. Lancet. 1992 Oct 3;340:801-7.



To evaluate the cost effectiveness of treating patients with symptomatic gallbladder stones with cholecystectomy or extracorporeal shock-wave lithotripsy.


Cost-effectiveness analysis based on a randomized controlled trial.


3 major hospitals in Sheffield, United Kingdom.


Effectiveness data were based on the results of a trial with 163 symptomatic patients with gallbladder stones for whom elective cholecystectomy was indicated. Exclusion criteria were pregnancy, liver damage, jaundice, acute pancreatitis, abnormal liver function tests, a dilated hepatic duct, a noncontracting gallbladder, abnormal clotting screen or platelet count, or a gallbladder that was inaccessible for ultrasonography or lithotripsy.


Open cholecystectomy was compared with piezoelectric extracorporeal shock-wave lithotripsy.

Main cost and outcome measures

Costs for lithotripsy included the costs of a suitability assessment, lithotripsy, ultrasonography, hospital stay, bile salts, and complications. Costs for cholecystectomy included costs of surgery, hospital stay, preoperative and postoperative tests, outpatient follow-up, and complications. Costs were measured over 1 year of follow-up (1989 to 1990). Effectiveness data were measured by differences in quality of life, biliary pain, and gastrointestinal and other symptoms, comparing those treated with cholecystectomy and those with lithotripsy.

Main results

Both treatments yielded significant health gains (reduction in episodes of biliary pain, improved perceived health status, and symptom relief) with few differences between treatments. For patients with large-bulk stones, lithotripsy with bile salts cost £778 {U.S. $1284}* more per patient than cholecystectomy. In the small-bulk-stone group, lithotripsy with bile salts cost £230 {U.S. $380}* more per patient than cholecystectomy. A one-way sensitivity analysis showed that the cost of lithotripsy fell below that of cholecystectomy only if there were no bile-salt costs or no hospital stay.


Inpatient piezoelectric extracorporeal shock-wave lithotripsy appeared to cost more than open cholecystectomy for symptomatic patients with large-bulk and, to a lesser degree, small-bulk stones, without providing greater improvement in health status.

Sources of funding: Department of Health of England and Wales; Trent Regional Health Authority; CP Pharmaceuticals.

For article reprint: Mr. J.P. Nicholl, Medical Care Research Unit, Department of Public Health Medicine, Sheffield University Medical School, Beech Hill Road, Sheffield S10 2BX, United Kingdom. FAX 44-1742-931-604.

*Numbers calculated from exchange rate for 1 January 1990 [1 £ = U.S. $1.65].


The randomized controlled trial by Nicholl and colleagues confirms previous projections about the relative cost effectiveness of extracorporeal shock-wave lithotripsy (ESWL) compared with open cholecystectomy for patients with symptomatic gallbladder stones (1). ESWL as compared with open cholecystectomy was associated with greater 1-year costs, with little difference between the 2 types of treatment in their effects on health-related quality of life. Also, the 24% stone-clearance rate in the group treated with piezoelectric ESWL in this trial re-inforces concerns about the ability to achieve stone-clearance rates as high as those initially reported for spark-gap ESWL by the Munich group (2), especially when using a different type of lithotriptor or less stringent eligibility criteria (3).

Although the U.S. Food and Drug Administration has not approved ESWL for use in the treatment of gallstones, ESWL may have a role in the treatment of a small subset of patients with symptoms that either have a small stone and a high surgical risk or a strong desire to avoid surgery. For most patients with symptomatic gallstones, cholecystectomy remains the treatment of choice. Further, laparoscopic cholecystectomy, now the preferred operative approach of most surgeons in North America, is associated with lower costs and lower operative mortality than open cholecystectomy for most patients with gallstone disease (4).

Eric B. Bass, MD, MPH
Johns Hopkins UniversityBaltimore, Maryland, USA


1. Bass EB, Steinberg EP, Pitt HA, et al. Cost-effectiveness of extracorporeal shock-wave lithotripsy versus cholecystectomy for symptomatic gallstones. Gastroenterology. 1991;101:189-99.

2. Sackmann M, Delius M, Sauerbruch T, et al. Shock-wave lithotripsy of gallbladder stones. The first 175 patients. N Engl J Med. 1988;318:393-7.

3. Barkun AN, Ponchon T. Extracorporeal biliary lithotripsy. Review of experimental studies and a clinical update. Ann Intern Med. 1990;112:126-37.

4. Bass EB, Pitt HA, Lillemoe KD. Cost-effectiveness of laparoscopic cholecystectomy versus open cholecystectomy. Am J Surg. 1993;165:466-71.