The Shah's Galling Gallstone

Doctors hope to remove it without using surgery

From the day the Shah of Iran arrived in the U.S. for medical treatment, news of his condition has centered on his six-year fight with cancer. But another painful disorder was the more immediate cause of his sudden flight to New York City: gallstones.

Within two days of being admitted to New York Hospital-Cornell Medical Center, the deposed monarch was in the operating room, where surgeons removed his stone-filled gall bladder. At the same time, they explored the bile ducts connecting the liver and gall bladder to the duodenum (the upper portion of the small intestine), looking for additional stones: As is sometimes the case in one of these difficult probes, at least one stone (in the common bile duct) escaped detection. Doctors have revealed that perhaps as soon as the end of this week they might attempt to remove the remaining stone--without surgery.

Gallstones are formed by bile, a fluid produced in the liver and stored in the gall bladder, that helps digest fats. Bile consists of a delicately balanced solution of cholesterol, bile acids and fatty substances. When it contains excessive cholesterol, bile crystallizes into stones that may be expelled into the ducts, blocking the flow of bile and usually causing severe pain. As bile backs up in the liver and is picked up and carried by the blood, it can give the skin the yellowish hue of jaundice.

About half a million people in the U.S. each year have their gall bladders removed and--in some of the cases--their bile ducts explored. Occasionally stones are missed or new ones form after surgery. For years the only remedy was to operate again. But within the past decade, physicians have devised several techniques to remove additional stones without cutting the patient open again.

For the Shah, doctors plan to make use of the channel formed by a rubber tube that was inserted through an opening in the abdomen and into the common bile duct during the initial operation to drain off bile. In such operations, doctors generally remove the tube, then insert a thinner, flexible catheter and advance it down the channel into the bile duct until it reaches the stone, which has been located by X rays. Then another tube, this one with a collapsed wire basket at its tip, is threaded through the catheter to the stone. With careful maneuvering, the stone is snared and both tubes are drawn out.

Doctors also have their choice of two other techniques. One, still experimental, involves circulating bile acids through the same channel into the bile duct and continuously bathing the stone until it is dissolved. The third method--used when no drainage tube has been inserted or when the stones are too large to pass through the drainage canal--is more complex.

Called endoscopic papillotomy, it was developed in Japan and Germany and is now beginning to find increasing favor in the U.S. A long, flexible, hollow tube called an endoscope is inserted into the patient's mouth and snaked down the esophagus, through the stomach, and into the duodenum to the juncture with the common bile duct. Fiberoptic bundles within the tube, which is only a centimeter (about two-fifths of an inch) in diameter, transmit light and allow the doctor to see where he is going.

Next a thin wire, covered with plastic except at its tip, is passed through the endoscope and positioned in the papilla, the nipple-like opening to the bile duct.

An electric current sent through this wire papillotome burns a larger opening in the papilla and cauterizes the wound. Stones can then pass from the bile duct into the duodenum and on through the intestine.

Or they can be retrieved by a wire basket threaded through the endoscope and extracted from the mouth of the sedated patient. The general anesthesia required in surgery is not necessary. Patients can eat on the same day and frequently resume their normal routine after only an overnight stay in the hospital. Dr. Jerome Siegel, a gastroenterologist at New York's Mt. Sinai School of Medicine, has used this method on about 150 patients and is sold on it. Says he: "Within 48 hours, one of my patients, a 58-year-old woman, played 18 holes of golf--and shot a better score than usual."

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