Using a ‘Stonebreaker’ to tackle salivary stones for the first time in Wales

Background:

Salivary stones are a significant problem causing facial pain, swelling and recurrent infections which, when severe, can require hospital admission.

Currently, at most units, surgical removal of the affected salivary gland under general anaesthetic remains the only treatment option available – implicating the well-documented surgical risks of anaesthesia. There are also the extra financial costs of general anaesthesia to consider, such as overnight stays and indirect costs to the individual, who has to take time off work, and to society in terms of a loss of productivity.

At the Royal Gwent Hospital, they have endeavoured to improve the management of these patients by purchasing a ‘Stonebreaker’, which can remove larger stones with minimally invasive techniques.

This is currently the only unit in Wales which is treating patients with small salivary stones using minimally invasive techniques, called sialendoscopy. Performed under local anaesthetic, small stones (less than 5mm) are visualised with tiny 1mm endoscopes and retrieved with baskets under direct vision. Larger stones greater than 5mm, however, cannot be easily managed with this technique alone.

Aims:

The aim of this project was to purchase a revolutionary intraductal salivary stone Lithotriptor ‘Stonebreaker’, which was previously trialed to facilitate the removal of larger stones. It was hoped that this equipment would allow more patients to be treated endoscopically with minimally invasive techniques and, therefore, avoid the need for major surgery.

Challenges:

The main challenge was securing the capital funding for the equipment. This was, however, eventually achieved following funding from the Bevan Commission and numerous discussions with the Finance and the Surgical Directorates at Aneurin Bevan University Health Board.

Once the equipment was purchased, training staff in its set-up, use and sterilisation was initially difficult. These barriers were overcome with excellent support from the industry partner (Cook Medical), who provided (and continue to provide) advice and training sessions for the surgeons and nursing staff.

Outcomes:

Using the ‘Stonebreaker’ for these cases has indeed proved revolutionary. It now allows patients and surgeons to consider a more conservative approach for all salivary stones.

The ‘Stonebreaker’ fragments the larger stones to aid removal using pneumatic lithotripsy under direct vision. It is performed under local anaesthetic with the mini endoscopes as previously described.

The obvious benefits are:

• A one hour procedure under local anaesthetic.
• Minimal complications with patients able to return to work the next day.
• General anaesthetic lists and ward beds are made available for other surgical procedures with obvious cost benefits.

The results have shown a 90% complete resolution of symptoms. The treatment has also been well tolerated under local anaesthetic, confirmed through a patient satisfaction questionnaire.

The project team has presented these early results at a national conference, and has found they are comparative with much larger studies in London and Germany.

Next steps:

The next steps for the project are to continue to promote the service throughout Wales:

• Advertise the procedure on the Health Board website and national maxillofacial website.
• Establishing in-house courses for surgeons both locally and nationally.
• Establishing a national database of surgeons carrying out this procedure in the UK.

The team is currently in the process of employing a further consultant in maxillofacial surgery with an interest in this field. This will help with the extra numbers of patients now being referred to the service from across South Wales to the newly titled ‘South Wales Sialendoscopy Unit’ based at the Royal Gwent Hospital, Newport.