Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study

Abstract

Background Endoscopic papillary large-balloon dilation (EPLBD) allows for the complete removal of large common bile duct (CBD) stones without fragmentation; however, a significant proportion of very large stones and stones floating above a tapering CBD require lithotripsy. Mechanical lithotripsy and cholangioscopy-guided laser lithotripsy are both effective for stone fragmentation. This study aimed to directly compare, for the first time, the efficacy of these two techniques in terms of stone clearance rate, procedure duration, patient radiation exposure, and safety. Methods 32 patients with very large CBD stones or with stones floating above a tapering CBD, and in whom extraction after standard sphincterotomy and/or EPLBD had failed, were randomly assigned to mechanical lithotripsy or cholangioscopy-guided laser lithotripsy at two tertiary referral centers. Crossover was allowed as a rescue treatment if the assigned technique failed. Results Patients’ demographic data were not different between the two groups. Mechanical lithotripsy had a significantly lower stone clearance rate in the first session compared with laser lithotripsy (63% vs. 100%; P < 0.01). Laser lithotripsy rescued 60% of patients with failed mechanical lithotripsy by achieving complete stone clearance within the same session. Radiation exposure of patients was significantly higher in the mechanical lithotripsy group than in the laser lithotripsy group (40 745 vs. 20 989 mGycm2; P = 0.04). Adverse events (13% vs. 6%; P = 0.76) and length of hospital stay (1 vs. 1 day; P = 0.27) were not different. Conclusions Although mechanical lithotripsy is the standard of care for a very large CBD stone after failed EPLBD, where available, cholangioscopy-guided laser lithotripsy is considered the better option for the treatment of this entity as it provides a higher success rate and lower radiation exposure.

Factors Associated with the Success Rate of Endoscopic Retrograde Cholangiopancreatography with Standard Technique followed by Laparoscopic Cholecystectomy in the Management of Choledocholithiasis: A Single-Center Experience

“…[11][12][13][14][15][16] ERCP with standard stone removal technique is the simplest procedure in endoscopy that most of the hospital can perform, whereas laser lithotripsy is available only in some tertiary centers especially in a low-or middle-income country. [17][18][19] It would be beneficial to the treatment planning if the success or failure of ERCP with the standard stone removal can be predicted, and a patient with a higher risk of OC conversion can be identified.…”

Recent advances in the management of difficult bile-duct stones: a focus on single-operator cholangioscopy-guided lithotripsy

“…However, this study investigated all kinds of cholangioscopy-guided lithotripsy, including SOC-guided lithotripsy. Recent studies focusing on SOC-guided lithotripsy reported seemingly better efficacy (Table 3) [19,26,27,[29][30][31][32][33][34].…”

“…Another randomized controlled trial by Angsuwatcharakon et al [33] compared SOC-guided LL and ML after a failed EPLBD. The complete stone removal rates in a single session were 100% and 63% with comparable adverse events (6% and 13%) in the SOC-guided LL and ML groups, respectively.…”

Management of Difficult Bile Duct Stones by Large Balloon, Cholangioscopy, Enteroscopy and Endosonography

“…9 There are two recent RCTs comparing POCS-assisted lithotripsy and the standard technique. 29,30 Buxbaum et al 29 compared POCS-assisted lithotripsy and the conventional technique including ML and EPLBD for BDS >1 cm. Complete stone removal rates were 93% in POCS-assisted lithotripsy and 67% in the conventional treatment without significant differences in the rates of adverse events (9.5% and 11.1%).…”

“…However, the procedure time was significantly longer in POCS-assisted lithotripsy group (120.7 and 81.2 minutes). Another RCT by Angsuwatcharakon et al 30 compared POCS-guided laser lithotripsy and ML after failed EPLBD. Complete stone removal rates in a single session were 100% and 63% with comparable adverse events (6% and 13%) in the POCS group and the ML group.…”