Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones

Endoscopic Management and Role of Interim Plastic Biliary Stenting in Large and Multiple Pigmented Common Bile Duct Stone

“…It has been reported that peroral endoscopic EHL is an effective means of managing difficult biliary stone disease, with fragmentation rates of 96% and stone clearance rates of 90%, 17 whereas laser lithotripsy has a success rate of 67 to 88%. [18][19][20][21] However, these techniques are limited to tertiary institutions or referral centers and are associated with a complication rate of 10% and a mortality rate of 1%. 23 In addition, there are still a significant percentage of difficult stones that cannot be removed even after mechanical lithotripsy, EHL or ESWL.…”

Intrahepatic Stones: The Percutaneous Approach

“…Intracorporeal cholangioscopic lithotripsy may be further improved by use of a new 'smart' laser with an automatic stone recognition system. This technique allows lithotripsy even under a limited direct visual control or under fluoroscopy (28)(29)(30)(31). This flashlamp-excited rhodamine-6G laser has a wavelength of 594 nm (Baasel Lasertech, Starnberg, Germany).…”

“…Several uncontrolled series demonstrated the efficacy and safety of 'smart' lithotripsy under fluoroscopy or cholangioscopy with miniscopes (28,29,31). The first randomized, controlled trial of intracorporeal laser lithotripsy (ILL) versus extracorporeal shock-wave lithotripsy (ESWL) was performed in 60 patients with bile duct stones in whom standard extraction including mechanical lithotripsy failed or in whom the papilla was not accessible, thus requiring percutaneous access (30). Bile duct clearance was achieved in 22 of 30 patients (73%) in the ESWL group and in 29 of 30 patients (97%) in the ILL group (P<0.05).…”

“…This study shows that ILL is more effective in the treatment of difficult bile duct stones than ESWL in terms of stone clearance rate and treatment duration. The smart laser can be used under fluoroscopic targeting without the need for cholangioscopic control (28,30). This approach is less technically demanding and probably more cost effective.…”

“…The advantage of the more expensive laser technique is that the fibres for transmission of the energy can be inserted through miniscopes, and the resulting stone fragments are smaller than fragments after EHL and, therefore, can be more easily removed through a stricture, the papilla or a biliodigestive anastomosis (23)(24)(25). The procedure is probably even safer when systems with an automatic stone recognition system are used because cholangioscopic vision can be limited due to stone fragments or biliary sludge (28)(29)(30)(31). In general, the image quality is much better than during peroral cholangioscopy because the instruments have more fibres than a babyscope or are equipped with a charge-coupled device chip and fragments can be better flushed away from the tip of the endoscope.…”