Cholangioscopy-guided electrohydraulic lithotripsy versus laser lithotripsy for the treatment of choledocholithiasis: a systematic review

Analysis of Efficacy and Safety of Laparoscopy Plus Choledochoscopy Combined With Holmium Laser Lithotripsy for Choledocholithiasis and Hepatolithiasis

Background

With the advancement of laparoscopic technology, the combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy has emerged as an effective treatment modality for both choledocholithiasis and hepatolithiasis. This study aimed to assess the efficacy and safety of this approach.

Methods

Retrospective analysis was conducted on the medical records of 76 patients diagnosed with choledocholithiasis and hepatolithiasis between April 2021 and March 2023. Patients were divided into two groups based on the treatment plan: the control group, which underwent traditional laparotomy and choledochoscopy lithotripsy (n = 38), and the experimental group, which underwent laparoscopy combined with choledochoscopy and holmium laser lithotripsy (n = 38). Comparative analysis was performed on various operation-related parameters, stone-free rate, complication rates, and changes in biochemical, liver function, inflammatory, stress response indicators, and pain scores between the two groups.

Results

The experimental group demonstrated significantly shorter stone removal time, reduced intraoperative bleeding, and shorter hospital stay compared to the control group (P < 0.05). Moreover, the experimental group exhibited lower incidence of postoperative complications and lower pain scores at 2 weeks to 3 months post-operation (P < 0.05). Biochemical indicators including total bile acid (TBA), total bilirubin (TBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and glutamyl transpeptidase (GGT) were significantly lower in the observation group compared to the control group (P < 0.05). Additionally, stress and inflammation indicators were also lower in the experimental group (P < 0.05).

Conclusions

The combination of laparoscopy, choledochoscopy, and holmium laser lithotripsy presents favorable therapeutic outcomes in the management of choledocholithiasis and hepatolithiasis, indicating its potential for widespread clinical application.

Direct peroral cholangioscopy with laser lithotripsy in treating choledocholithiasis - single-institution experience

<b>Introduction:</b> Choledocholithiasis (CCL) is one of the most common serious health consequences of cholelithiasis. For years, evacuation of stones using endoscopic retrograde cholangiopancreatography (ERCP) has been the first-line treatment. In 10-15% of cases, gallstones cannot be removed using the above-mentioned method and auxiliary methods are necessary; these are so-called difficult gallstones. Surgical treatment is sometimes necessary. The European Society of Gastrointestinal Endoscopy (ESGE) has recommended the use of cholangioscopy, including direct peroral cholangioscopy (DPOC), as one of the main treatment methods since 2015.<b>Aim:</b> The following article aims to investigate the safety and efficacy of direct cholangioscopy with laser lithotripsy in the treatment of CCL.<b>Materials and methods:</b> The study was conducted at the Department of General and Transplant Surgery, Medical University of Lodz. From October 2022 to November 2023, 13 procedures of difficult gallstone evacuation from the bile duct were performed using the technique of direct cholangioscopy with laser lithotripsy.<b>Results:</b> Thirteen cases of difficult gallstones were retrospectively analyzed. The bile duct was intubated via the ampulla of Vater using direct cholangioscopy. The bile duct was cleared of gallstones using laser lithotripsy, followed by a Dormia basket or an extraction balloon to remove stone fragments. The procedure was performed successfully in all patients. No complications were observed.<b>Conclusions:</b> DPOC with laser lithotripsy seems to be an effective and safe method of clearing even very large gallstones from the bile duct. The relatively low price of tools and the resulting cost reduction may allow this procedure to become more popular.

Safety Parameters for the Use of Holmium:YAG Laser in the Treatment of Biliary Calculi: The Ex-Vivo Model

Background and Objectives: While studies have demonstrated the efficacy of cholangioscopy-guided Holmium-Yttrium aluminum garnet (Ho:YAG) laser lithotripsy for the treatment of refractory bile duct stones, data regarding the safety of the operating parameters for laser lithotripsy are lacking. The aim of this study was to determine safe, yet effective, energy settings for Ho:YAG laser in the ex-vivo model. Materials and Methods: This ex vivo experimental study utilized the Ho:YAG laser on porcine bile duct epithelium and human gallstones. Ho:YAG laser lithotripsy was applied in different power settings from 8 to 15 Watts (W) to six explanted porcine bile ducts. Settings that appeared safe were then utilized to fragment seventy-three human gallstones. Results: The median bile duct perforation times with the Ho:YAG laser between 8-15 W were: >60 s (8 W); 23 s (9 W); 29 s (10 W); 27 s (12 W); 12 s (14 W); and 8 s (15 W). Statistically significant differences in the median perforation times were noted between 8 W vs. 15 W, 9 W vs. 15 W, 10 W vs. 15 W, and 12 W vs. 15 W (p < 0.05). When using a 365 µm Ho:YAG laser probe at 8-12 W, the fragmentation rates on various size stones were: 100% (<1.5 cm); 80-100% (1.6-2.0 cm) and 0-32% (>2.0 cm). Optimal fragmentation was seen utilizing 12 W with high energy (2.4 J) and low frequency (5 Hz) settings. Using a larger 550 µm probe at these settings resulted in 100% fragmentation of stones larger than 2 cm. Conclusions: The Ho:YAG laser appears to be safe and effective in the treatment of large bile duct stones when used between 8-12 W in 5 s bursts in an ex vivo model utilizing porcine bile ducts and human gallstones.

Current trends of minimally invasive therapy for cholecystocholedocholithiasis

Introduction

The minimally invasive approach of endoscopic ultrasound (EUS)-guided procedures for cholecystocholedocholithiasis, such as EUS-guided gallbladder drainage (EUS-GBD), EUS-guided rendezvous (EUS-RV), and EUS-guided biliary drainage (EUS-BD), is affirmed as an effective treatment for patients with acute cholecystitis (AC) who are unfit for surgery and for patients with common bile duct stones (CBDSs) who have experienced a previous ERCP failure. Furthermore, in cases of difficult CBDS extraction during endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy-guided electrohydraulic lithotripsy (CS-EHL) has showed optimal results. The main objective of our study was to evaluate the effectiveness of EUS-GBD and percutaneous gallbladder drainage (PT-GBD) in patients with AC who are unfit for surgery. We also aimed to evaluate the efficacy of EUS-GBD, EUS-BD, and EUS-RV following ERCP failure and the effectiveness of CS-EHL for difficult CBDS extraction in our hospital. The secondary aim was to examine the safety of these procedures.

Materials and methods

We conducted a retrospective evaluation of all the EUS-GBD, PT-GBD, EUS-BD, EUS-RV, and CS-EHL procedures, which were prospectively collected in the gastroenterology and digestive endoscopy unit and the general surgery unit from January 2020 to June 2023. The efficacy was expressed in terms of technical and clinical success rates, while safety was assessed based on the rate of adverse events (AEs).

Results

We enrolled 83 patients with AC and high surgical risk. Among them, 57 patients (68.7%, 24/57 male, median age 85 ± 11 years) underwent EUS-GBD, and 26 (31.3%, 19/26 male, median age 83 ± 7 years) underwent PT-GBD. The technical and clinical success rates were 96.5 and 100% for EUS-GBD, and 96.1 and 92% for PT-GBD. The AEs for EUS-GBD were 1.7%, and for PT-GBD, it was 12%. ERCP for CBDS extraction failed in 77 patients. Among them, 73 patients (94.8%) underwent EUS-RV with technical and clinical success rates of 72.6% (53/73) and 100%, respectively. No AEs were reported. Four out of 77 patients were directly treated with EUS-BD for pyloric inflammatory stenosis. In 12 patients (16.4%), following unsuccessful EUS-RV with a CBD diameter ≥ 12 mm, an EUS-BD was performed. Both technical and clinical success rates for EUS-BD were 100%, and no AEs were reported. EUS-GBD was the treatment of choice for the remaining 8 (10.9%) patients after failure of both ERCP and EUS-RV. The procedure had high technical and clinical success rates (both at 100%), and no AEs were reported. The 12 difficult CBDS extraction treated with CS-EHL also showed high technical and clinical success rates (both at 100%), with no reported AEs.

Conclusion

The minimally invasive approach for cholecystocholedocholithiasis, especially EUS-guided procedures, had high efficacy and safety in treating AC in high-risk surgical patients and CBDS extraction after a previously unsuccessful ERCP.

The Role of Cholangioscopy in Biliary Diseases

Endoscopy plays a central role in diagnostic and therapeutic approaches to biliary disease in both benign and malignant conditions. A cholangioscope is an endoscopic instrument that allows for the direct exploration of the biliary tree. Over the years, technology has improved endoscopic image quality and allowed for the development of an operative procedure that can be performed during cholangioscopy. Different types of instruments are available in this context, and they can be used in different anatomical access points according to the most appropriate clinical indication. The direct visualization of biliary mucosa is essential in the presence of biliary strictures of unknown significance, allowing for the appropriate allocation of patients to surgery or conservative treatments. Cholangioscopy has demonstrated excellent performance in discriminating malignant conditions (such as colangiocarcinoma) from benign inflammatory strictures, and more recent advances (e.g., artificial intelligence and confocal laser endomicroscopy) could further increase its diagnostic accuracy. Cholangioscopy also plays a primary role in the treatment of benign conditions such as difficult bile stones (DBSs). In this case, it may not be possible to achieve complete biliary drainage using standard ERCP. Therapeutic cholangioscopy-guided lithotripsy allows for stone fragmentation and complete biliary drainage. Indeed, other complex clinical situations, such as patients with intra-hepatic lithiasis and patients with an altered anatomy, could benefit from the therapeutic role of cholangioscopy. The aim of the present review is to explore the most recent diagnostic and therapeutic advances in the roles of cholangioscopy in the management of biliary diseases.