Skip to main content
SpringerLink
Log in

Factors Influencing Performance of Cholangioscopy-Guided Lithotripsy Including Available Different Technologies: A Prospective Multicenter Study with 94 Patients

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

Peroral cholangioscopy (POC)-guided lithotripsy is an effective treatment for difficult biliary stones. A clear definition of factors associated with the efficacy of POC-guided lithotripsy in one session and the performance of electrohydraulic lithotripsy (EHL) and laser lithotripsy (LL) have not clearly emerged.

Methods

This was a non-randomized prospective multicenter study of all consecutive patients who underwent POC lithotripsy (using EHL and/or LL) for difficult biliary stones. The primary endpoint of the study was the number of sessions needed to achieve complete ductal clearance and the factors associated with this outcome. Secondary endpoints included the evaluated efficacies of LL and EHL.

Results

Ninety-four patients underwent 113 procedures of EHL or LL. Complete ductal clearance was obtained in 93/94 patients (98.94%). In total, 80/94 patients (85.11%) achieved stone clearance in a single session. In the multivariate analysis, stone size was independently associated with the need for multiple sessions to achieve complete ductal clearance (odds ratio = 1.146, 95% confidence interval: 1.055–1.244; p = 0.001). Using ROC curves and the Youden index, 22 mm was found to be the optimal cutoff for stone size (95% confidence interval: 15.71–28.28; p < 0.001). The majority of the patients (62.8%) underwent LL in the first session. Six patients failed the first session with EHL after using two probes and therefore were crossed over to LL, obtaining ductal clearance in a single additional session with a single LL fiber. EHL was significantly associated with a larger number of probes (2.0 vs. 1.02) to achieve ductal clearance (p < 0.01). The mean procedural time was significantly longer for EHL than for LL [72.1 (SD 16.3 min) versus 51.1 (SD 10.5 min)] (p < 0.01).

Conclusions

POC is highly effective for difficult biliary stones. Most patients achieved complete ductal clearance in one session, which was significantly more likely for stones < 22 mm. EHL was significantly associated with the need for more probes and a longer procedural time to achieve ductal clearance.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Availability of data and material

The datasets generated and/or analyzed in the present study are available from the corresponding author on reasonable request.

Abbreviations

POC:

Peroral cholangioscopy

EHL:

Electrohydraulic lithotripsy

LL:

Laser lithotripsy

EST:

Endoscopic sphincterotomy

EPLBD:

Endoscopic papillary large balloon dilation

SOC:

Single-operator cholangioscopy

References

  1. Aburajab M, Dua K. Endoscopic management of difficult bile duct stones. Curr Gastroenterol Rep 2018;20:8.

    Article  Google Scholar 

  2. Canena J, Lopes L, Fernandes J, Alexandrino G, Lourenço L, Libânio D et al. Outcomes of single-operator cholangioscopy-guided lithotripsy in patients with difficult biliary and pancreatic stones. GE Port J Gastroenterol 2019;26:105–113.

    Article  Google Scholar 

  3. Yasuda I, Itoi T. Recent advances in endoscopic management of difficult bile duct stones. Dig Endosc 2013;25:376–385.https://doi.org/10.1111/den.12118.

    Article  PubMed  Google Scholar 

  4. Canena J. Once upon a time a guideline was used for the evaluation of suspected choledocholithiasis: A fairy tale or a nightmare? GE Portug J Gastroenterol 2018;25:6–9.

    Article  Google Scholar 

  5. Misra SP, Dwivedi M. Large-diameter balloon dilation after endoscopic sphincterotomy for removal of difficult bile duct stones. Endoscopy 2008;40:209–213.

    Article  CAS  Google Scholar 

  6. Leung JW, Chung SS. Electrohydraulic lithotripsy with peroral choledochoscopy. BMJ (Clin Res Ed) 1989;299:595–598.

    Article  CAS  Google Scholar 

  7. Lux G, Ell C, Hochberger J, Müller D, Demling L. The first successful endoscopic retrograde laser lithotripsy of common bile duct stones in man using a pulsed neodymium-YAG laser. Endoscopy 1986;18:144–145.

    Article  CAS  Google Scholar 

  8. Nakajima M, Akasaka Y, Yamaguchi K, Fujimoto S, Kawai K. Direct endoscopic visualization of the bile and pancreatic duct systems by peroral cholangiopancreatoscopy (PCPS). Gastrointest Endosc 1978;24:141–145.

    Article  CAS  Google Scholar 

  9. Wong JC, Tang RS, Teoh AY, Sung JJ, Lau JY. Efficacy and safety of novel digital single-operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones. Endosc Int Open 2017;5:E54–E58.

    Article  Google Scholar 

  10. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: A clinical feasibility study (with video). Gastrointest Endosc 2007;65:832–841.

    Article  Google Scholar 

  11. Bang JY, Sutton B, Navaneethan U, Hawes R, Varadarajulu S. Efficacy of single-operator cholangioscopy-guided lithotripsy compared with large balloon sphincteroplasty in management of difficult bile duct stones in a randomized trial. Clin Gastroenterol Hepatol 2020;18:2349-2356.e3.

    Article  Google Scholar 

  12. Laleman W, Verraes K, van Steenbergen W, Cassiman D, Nevens F, van der Merwe S et al. Usefulness of the single-operator cholangioscopy system SpyGlass in biliary disease: A single-center prospective cohort study and aggregated review. Surg Endosc 2017;31:2223–2232.

    Article  Google Scholar 

  13. Tsuyuguchi T, Sakai Y, Sugiyama H, Ishihara T, Yokosuka O. Long-term follow-up after peroral cholangioscopy-directed lithotripsy in patients with difficult bile duct stones, including Mirizzi syndrome: An analysis of risk factors predicting stone recurrence. Surg Endosc 2011;25:2179–2185.

    Article  Google Scholar 

  14. Navaneethan U, Hasan MK, Kommaraju K, Zhu X, Hebert-Magee S, Hawes RH et al. Digital, single-operator cholangiopancreatoscopy in the diagnosis and management of pancreatobiliary disorders: a multicenter clinical experience (with video). Gastrointest Endosc [Internet] 2016;84:649–55. https://doi.org/10.1016/j.gie.2016.03.789.

    Article  Google Scholar 

  15. Franzini T, Moura R, Bonifácio P, Luz G, de Souza T, dos Santos M et al. Complex biliary stones management: Cholangioscopy versus papillary large balloon dilation—A randomized controlled trial. Endoscopy International Open 2018;06:E131–E138.

    Article  Google Scholar 

  16. Maydeo AP, Rerknimitr R, Lau JY, Aljebreen A, Niaz SK, Itoi T et al. Cholangioscopy-guided lithotripsy for difficult bile duct stone clearance in a single session of ERCP: Results from a large multinational registry demonstrate high success rates. Endoscopy 2019;51:922–929.

    Article  Google Scholar 

  17. Brewer Gutierrez OI, Bekkali NLH, Raijman I, Sturgess R, Sejpal DV, Aridi HD et al. Efficacy and safety of digital single-operator cholangioscopy for difficult biliary stones. Clin Gastroenterol Hepatol 2018;16:918–926.e1. https://doi.org/10.1016/j.cgh.2017.10.01718.

    Article  PubMed  Google Scholar 

  18. McCarty TR, Gulati R, Rustagi T. Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: A systematic review and meta-analysis. Endoscopy 2021;53:110–122. https://doi.org/10.1055/a-1200-8064.

    Article  PubMed  Google Scholar 

  19. Kedia P, Tarnasky PR. Endoscopic management of complex biliary stone disease. Gastrointest Endosc Clin N Am 2019;29:257–275.

    Article  Google Scholar 

  20. Binmoeller KF, Brückner M, Thonke F, Soehendra N. Treatment of difficult bile duct stones using mechanical, electrohydraulic and extracorporeal shock wave lithotripsy. Endoscopy 1993;25:201–206.

    Article  CAS  Google Scholar 

  21. Das AK, Chiura A, Conlin MJ, Eschelman D, Bagley DH. Treatment of biliary calculi using holmium: Yttrium aluminum garnet laser. Gastrointest Endosc 1998;48:207–209.

    Article  CAS  Google Scholar 

  22. Adamek HE, Buttmann A, Wessbecher R, Kohler B, Riemann JF. Clinical comparison of extracorporeal piezoelectric lithotripsy (EPL) and intracorporeal electrohydraulic lithotripsy (EHL) in difficult bile duct stones. A prospective randomized trial. Dig Dis Sci 1995;40:1185–92.

    Article  CAS  Google Scholar 

  23. Hui C-K, Lai K-C, Ng M, Wong W-M, Yuen M-F, Lam S-K et al. Retained common bile duct stones: A comparison between biliary stenting and complete clearance of stones by electrohydraulic lithotripsy. Aliment Pharmacol Ther 2003;17:289–296.

    Article  Google Scholar 

  24. Chen YK, Pleskow DK. SpyGlass single-operator peroral cholangiopancreatoscopy system for the diagnosis and therapy of bile-duct disorders: a clinical feasibility study (with video){A figure is presented}. Gastrointest Endosc 2007;65:832–841.

    Article  Google Scholar 

  25. Bokemeyer A, Gerges C, Lang D, Bettenworth D, Kabar I, Schmidt H et al. Digital single-operator video cholangioscopy in treating refractory biliary stones: A multicenter observational study. Surg Endosc [Internet] 2020;34:1914–22. https://doi.org/10.1007/s00464-019-06962-0.

    Article  Google Scholar 

  26. Wong JC, Tang RS, Teoh AY, Sung JJ, Lau JY, Bhandari S et al. Efficacy and safety of novel digital single-operator peroral cholangioscopy-guided laser lithotripsy for complicated biliary stones. Endosc Int Open 2017;5:E54–E58.

    Article  Google Scholar 

  27. Patel MS, Davis MM, Lypson ML, Gilman W, Matthew DSL, Bosanquet N, Oppong R et al. Health economics education in undergraduate medical training: Introducing the health economics education (HEe) website. BMC Med Educ [Internet] 2013;15:126.

    Google Scholar 

  28. Patel SN, Rosenkranz L, Hooks B, Tarnasky PR, Raijman I, Fishman DS et al. Holmium-yttrium aluminum garnet laser lithotripsy in the treatment of biliary calculi using single-operator cholangioscopy: A multicenter experience (with video). Gastrointest Endoscop 2014;79:344–348.

    Article  Google Scholar 

Download references

Funding

There was no funding for this research.

Author information

Author notes

  1. Gonçalo Alexandrino and Luis Lopes contributed equally to this manuscript and they should be considered both first authors.

Authors and Affiliations

  1. Gastroenterology Department, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal

    Gonçalo Alexandrino, Luísa Figueiredo, Luís Carvalho Lourenço, David Horta & Jorge Canena

  2. Gastroenterology Department, Hospital de Santa Luzia, Unidade Local de Saúde do Alto Minho, Viana do Castelo, Portugal

    Luís Lopes, João Fernandes, Marta Moreira & Tarcísio Araújo

  3. Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal

    João Fernandes & Sara Campos

  4. Gastroenterology Department, Hospital Beatriz Ângelo, Loures, Portugal

    Rui Loureiro

  5. Gastroenterology Department, Hospital Egas Moniz – Centro Hospital Lisboa Ocidental, Lisbon, Portugal

    Tiago Bana e Costa

  6. School of Medicine, Life and Health Sciences Research Institute (ICVS), Universidade do Minho, Braga, Portugal

    Luís Lopes & Patrício Costa

  7. ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal

    Luís Lopes & Patrício Costa

  8. Gastroenterology University Center – Hospital Cuf Tejo, Lisbon, Portugal

    Jorge Canena

  9. Gastroenterology Department - Nova Medical School, Faculty of Medical Sciences, Hospital Cuf Tejo, Avenida 24 de Julho, 171A, 1350-352, Lisbon, Portugal

    Jorge Canena

  10. Cintesis – Center for Health Technology and Services Research, Porto, Portugal

    Jorge Canena

Authors
  1. Gonçalo Alexandrino
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Luís Lopes
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. João Fernandes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Marta Moreira
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tarcísio Araújo
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Sara Campos
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Rui Loureiro
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Luísa Figueiredo
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Luís Carvalho Lourenço
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. David Horta
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Tiago Bana e Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Patrício Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Jorge Canena
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Gonçalo Alexandrino contributed to performing procedures, collection of data, analysis and interpretation of data, and drafting the manuscript; Luis Lopes contributed to conception and design of the study, performing procedures, collection of data, analysis and interpretation of data, and drafting the manuscript; João Fernandes contributed to conception and design of the study, collection of data, critical revision of the manuscript, and approval of the final draft submitted; Marta Moreira contributed to collection of data, critical revision of the manuscript, and approval of the final draft submitted; Tarcísio Araújo contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; Sara Campos contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; Rui Loureiro contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; Luísa Figueiredo contributed to collection of data, critical revision of the manuscript, and approval of the final draft submitted; Luís Carvalho Lourenço contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; David Horta contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; Tiago Bana e Costa contributed to collection of data, preforming procedures, critical revision of the manuscript, and approval of the final draft submitted; Patricio Costa contributed to statistical analysis, critical revision of the manuscript, and approval of the final draft submitted; and Jorge Canena contributed to conception and design of the study, collection of data, analysis and interpretation of data, performing procedures and drafting the manuscript.

Corresponding author

Correspondence to Jorge Canena.

Ethics declarations

Conflict of interests

Jorge Canena is an International Consultant for Boston Scientific but did not receive any financial arrangements for this research, or any assistance with manuscript preparation. The remaining authors declare that they have no competing interests.

Ethics approval

This study was conducted in compliance with the International Conference on Harmonization guidelines for Good Clinical Practice (E6) and the 2013 Declaration of Helsinki. All patients provided written informed consent before inclusion in the study. This observational study was approved by local Ethics Committees of 6 hospitals (ULSAM 44/2018, EDOC/ULSBA/15191, EC/56-2018, HGO 23/18, HEM-CHLO 060618 and HBA 2121/18).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Video showing bursts of an electrohydraulic probe for fragmentation of a stone. (MPG 14432 kb)

video showing complete setting of Cholangioscopy-guided laser lithotripsy for multiples stones of the bile duct. (MPG 20756 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Alexandrino, G., Lopes, L., Fernandes, J. et al. Factors Influencing Performance of Cholangioscopy-Guided Lithotripsy Including Available Different Technologies: A Prospective Multicenter Study with 94 Patients. Dig Dis Sci 67, 4195–4203 (2022). https://doi.org/10.1007/s10620-021-07305-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-021-07305-7

Keywords

Search

Navigation