Outcome of the Management of Salivary Gland Diseases by Sialendoscopy: A University Hospital's Experience

PURPOSE

Sialendoscopy is a minimally invasive procedure for the treatment of salivary gland diseases. The purpose of this study was to review a series of the patients undergoing sialendoscopy and to present our experience regarding the management and outcome of obstructive sialadenitis treated by this procedure.

METHODS

This study was a case series. We collected data on patients who underwent sialendoscopy in our institute between January 2016 and July 2019. The data included patients' demographics, involved salivary glands, diagnostic investigation, types of anesthesia, endoscopic findings, materials used, complications, adjunctive treatment, duration of follow-up, and therapeutic outcome. Descriptive statistics were used to analyze the surgical findings and outcome.

RESULTS

There were 61 patients involving 76 glands (48 submandibular and 29 parotid glands). There were 43 females and 18 males with the median age 45 years at the time of sialendoscopy. The median duration of follow-up was 6 months. The most dominant symptom was pain with swelling (59.20%). The 2 most common sialendoscopic findings were ductal stenosis and sialolithiasis. We observed a success rate in achieving a complete relief of 77.6% at the first procedure and 96.7% at the last follow-up. We did not have any cases with postoperative complication or recurrence.

CONCLUSION

Our study supports sialendoscopy as a safe and successful procedure that plays a dual role in diagnostics and in relieving symptoms of patients with obstructive sialadenitis with or without sialolithiasis. It should be advised for patients with non-neoplastic salivary duct obstruction either for diagnosis or therapeutic intervention.

A Novel Approach for the Treatment of Sialolithiasis that Preserves Salivary Duct Anatomy

OBJECTIVE

The sialendoscopy era in the treatment of salivary gland stones has reduced the use of classical surgical methods. However, the miniature ducts and tools may cause difficulties in removing large sialoliths. Therefore, invasive combined oral surgeries or gland resection may be considered. We searched for the most suitable method in order to stay in line with the minimally invasive approach that preserves the ductus anatomy, and that can reduce the surgical fears of patients.

MATERIALS AND METHODS

The study included 84 cases (23 parotid and 61 submandibular) in whom stones were fragmented by pneumatic lithotripsy and removed between January 2015 and January 2020. The parotid cases comprised 7 females and 16 males, and the submandibular cases comprised 25 females and 36 males. Intraductal lithotripsy was performed using pneumatic lithotripter. This study has fourth level of evidence.

RESULTS

Based on total number of cases (n = 84), success rate was 67/84 (79.7%) immediately after sialendoscopy, and overall success rate was 77/84 (91.6%). Based on number of stones treated (n = 111), our immediate success rate was 94/111 (84.6%), and overall success rate was 104/111 (93.7%). The success criteria were complete removal of the stone and fragments in a single sialendoscopy procedure and resolution of symptoms.

CONCLUSIONS

We successfully treated salivary gland stones, including L3b stones, in our patient cohort with sialendoscopy combined with pneumatic lithotripsy. The lithotripsy method that we have adapted seems to be more useful and cost-effective compared to its alternatives. We were also able to preserve the ductus anatomy and relieve patients' concerns.Level of Evidence: Level IV.

Intraductal Lithotripsy in Sialolithiasis Using the Calculase III™ Ho:YAG Laser: First Experiences

BACKGROUND AND OBJECTIVES

To report the first experiences with a newly available Ho:YAG laser system for the treatment of salivary stones.

STUDY DESIGN/MATERIALS AND METHODS

A retrospective study in a tertiary referral center was conducted. Patients diagnosed with sialolithiasis were treated in Erlangen using the Calculase III™ Ho:YAG laser (Karl Storz, Tuttlingen, Germany). Preset parameters had a frequency of 4 Hz and energy of 0.8-1.2 J, resulting in 3.2-4.8 W. Following total fragmentation, one to two serial sialendoscopies were performed to achieve complete fragment clearance.

RESULTS

A total of 55 stones in 49 patients were treated; 17 stones in 15 submandibular glands and 38 in 34 parotids. In total, 61 laser lithotripsies (range 1-3 per stone) were performed using various modes (long, short, and burst) and with preset parameters of 4 Hz and energy of 0.8-1.2 J, resulting in effective power of 3.2-4.8 W. Complete fragmentation was achieved in all the accessible stones. Sialendoscopes, fibers, or the mode used had no significant influence on success rates. A multimodal therapy concept was employed to treat stones in 12.24% of the cases; 95.92% of the patients were ultimately stone-free, and all became symptom-free. All glands were preserved.

CONCLUSIONS

The new Calculase III™ Ho:YAG laser was effective in the treatment of sialolithiasis with no increased risk of complications in the patients or damage to the sialendoscopes. Clinical factors such as the type of gland involved, or the location and size of stones had a greater impact on success rates than the technical or preset parameters. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Success rate and complications of sialendoscopy and sialolithotripsy in patients with parotid sialolithiasis: a systematic review

PURPOSE

To assess the success rate and complications of sialendoscopy and sialolithotripsy for parotid sialolithiasis.

MATERIALS AND METHODS

A total of 228 articles were identified by the electronic database search regarding the topics sialendoscopy and sialolithotripsy. Following independent then joint review of titles and abstracts, 109 articles were selected for the full review. Thirteen of these were chosen for data extraction from which 1285 patients with parotid salivary stones were identified. Extracted data included number of patients, age, gender, location, management, and outcomes.

RESULTS

All articles combined, 1285 patients with parotid salivary stones were included with a successful treatment in 1139 patients. The success rated ranged from 71.4 to 100% with a mean of 88.7%. Both partial as complete success was achieved. Although minor complications were frequent, no major complications occurred.

CONCLUSIONS

Sialendoscopy and sialolithotripsy are best suited as first choice treatment-if conservative therapy failed-for the management of parotid gland sialolithiasis. It is a valuable and feasible treatment option with no major complications. Selection of cases will ensure the best prognosis. Although there is no indefinite stone size, the smaller the calculus, the greater the probability of a symptom-free patient.

Does diabetes mellitus affect the parotid ductal system? A sialendoscopic evaluation

OBJECTIVE

The aim of this study was to assess the existence of ductal changes in diabetics using sialendoscopy.

STUDY DESIGN

Twenty patients and 10 volunteers received bilateral parotid diagnostic sialendoscopy. Group I included 10 patients with uncontrolled diabetes (UCD); group II, 10 patients with controlled diabetes (CD); and group III, 10 nondiabetic controls (CG). Expected ductal changes were examined in 3 proposed distinct zones. A χ² test was used to compare groups.

RESULTS

Ductal pathologic conditions were significantly higher in diabetic patients in all zones. Abnormalities were classified as stenosis, hyperemia, or others. In UCD, stenosis percentage was 55%, 90%, and 100% in zones 1, 2, and 3, respectively, compared with 30%, 40%, and 55% in CD and 5%, 5%, and 0% in CG (P < .01). Hyperemic changes in UCD were 90%, 90%, and 40% compared with 50%, 50%, and 20% in CD (P < .01) and 0% in CG. Comparing zones in UCD and CD indicated that stenosis increased significantly toward the proximal end, whereas hyperemia prevailed toward the distal end.

CONCLUSIONS

Significant ductal abnormalities were detected in the parotids of UCD and CD patients compared with CG. Ductal changes were higher in UCD compared with CD.

Long-Term Outcomes of Sialendoscopy in the Management of Sialolithiasis and Idiopathic Chronic Sialadenitis with Ductal Scars

Objective

We aimed to present the long-term outcomes and sialendoscopic findings in only patients with sialolithiasis and ductal scars in idiopathic chronic recurrent sialadenitis who experienced unsuccessful results with conservative treatment and were treated with sialendoscopy.

Methods

We retrospectively analyzed the patients with a diagnosis of only sialolithiasis and ductal scars in chronic recurrent sialadenitis who underwent sialendoscopy between January 2011 and June 2016. We collected clinical and intraoperative data including patient age, sex, date of the procedure, the involved gland, operative findings and complications. Follow-up data included whether the symptoms were resolved or recurred and whether any further procedures were performed.

Results

Of a total of 38 patients, 16 were excluded from the study due to missing clinical or follow-up data, and analysis was conducted on 22 patients. Twelve were diagnosed with sialolithiasis, while the remaining 10 were diagnosed with idiopathic chronic sialadenitis and had ductal scars. Stone sizes ranged from 2 mm to 10 mm. Mean follow-up time was 39.5 months. The final success rate was 100%. Of the 10 patients with ductal scarring, five had scar in the parotid gland duct, and five in the submandibular gland duct. The mean follow-up time of all ductal scar patients was 47.1 months. The final success rate was 70%.

Conclusion

Sialendoscopy is a minimally invasive method for the diagnosis and treatment of sialolithiasis and ductal scars of the salivary glands after failure of conservative treatments in adults.

Learning curve in diagnostic and interventional sialendoscopy for obstructive salivary diseases

Sialendoscopy is a new diagnostic and surgical tool for management of salivary gland diseases that offers the opportunity to treat selected pathologies less invasively and with better results compared to previous techniques. As with any new technique, an adequate training programme involving a gradual learning curve is mandatory to quickly obtain results similar to those reported in the literature. This includes an appropriate diagnostic programme, correct patient selection and knowledge of possible pitfalls. In this retrospective study, the outcomes of the first 141 procedures (74 on the parotid gland and 67 on the submandibular gland) performed with this technique in our Department from 2009 to 2013 were compared with those reported in the literature. Patients were divided into three groups: Group A (the first 49 procedures performed), Group B (the next 50 procedures), and Group C (the last 42 procedures). There were no statistically significant differences relative to mean procedure times, recurrence of symptomatology after treatment, need for further treatments and rates of minor complications between groups. No major complications were seen. The increase in experience resulted in an increased number of interventional sialendoscopies performed under local anaesthesia instead of general anaesthesia (51% vs 18% vs 14%). In only three of 130 glands treated (2.3%) was gland resection required. We also evaluated which technique had been used for stone removal and rate of failure, which was similar in all groups (13.6% vs 15% vs 15%). Our results do not substantially differ from those reported in the literature. Initial difficulties in catheterising the papilla could be overcome with practise on fresh human specimens or fresh pig heads. Lack of precision regarding diagnostic imaging techniques was remedied by improving the competence of the surgeon in performing pre- and postoperative ultrasound. The creation of specialised centres capable of treating up to 1 to 2 million people would be desirable in order to better stratify pathologies, validate the investment in equipment and gain the necessary experience in the various surgical techniques.

Sialendoscopic Pneumatic Lithotripsy for Salivary Calculi: A New Technique and a Long-term Clinical Experience

We report our results comprising a series of 34 cases of sialolithiasis that were approached sialendoscopically with conventional instruments (ie, basket and/or forceps) and for which stone removal was unsuccessful and so were thereafter treated with pneumatic lithotripsy. Intraductal pneumatic lithotripsy was able to fragment 30 of 34 (88%) salivary calculi in total. No major complications occurred. All 30 treated glands returned to normal function without any symptoms. We believe that the success of sialendoscopy is closely related to the success of salivary stone fragmentability.

Salivary lithotripsy in the era of sialendoscopy

The traditional management of obstructive salivary disorders has been replaced by minimally-invasive gland-preserving techniques including shock-wave lithotripsy, sialendoscopy, interventional radiology and endoscopically video-assisted trans-oral and cervical stone retrieval, of which sialendoscopy is considered to be the method of first choice. Primary endoscopically controlled stone extraction without prior fragmentation is only possible in 15-20% of cases; in more than 80%, fragmentation is necessary because of the size, impactation and location of the stone, or an alternative treatment such as transoral duct surgery or combined approaches are required. Moreover, about 10-20% of all stones cannot be adequately accessed by means of a sialendoscope or any alternative surgical method and, in such cases, extra-corporeal shock wave lithotripsy (ESWL) is the treatment of choice. However, in endoscopically accessible stones, ESWL is being gradually replaced by endoscopically assisted intra-corporeal techniques, including endoscopically guided laser and pneumatic intracorporeal lithotripsy. We describe the currently most widely used techniques for salivary lithotripsy, including ESWL, and endoscopically guided laser, electrohydraulic, electrokinetic and pneumatic intra-corporeal lithotripsy, and discuss their indications given the widespread use of advanced rehabilitative sialendoscopy and combined therapeutic approaches.

Salivary Stone Pneumatic Lithotripsy in a Live Porcine Model

The purpose of this study is to evaluate the efficacy of endoscopic fragmentation and removal of artificial calculi in a live porcine model employing intracorporeal pneumatic lithotripsy. In this experimental study, 7 submandibular ducts were accessed and artificial calculi placed. A salivary pneumatic lithotripter probe was inserted through an interventional sialendoscope to fragment the calculi. A salivary duct catheter was then used to flush stone fragments, followed by endoscopy to assess complete fragmentation and ductal trauma. Ultimately, 7 artificial stones (3-10 mm, 4F/5F) were successfully fragmented without causing significant endoluminal trauma. Number of pulses for adequate stone fragmentation averaged 20 (range, 5-31). In all cases, stone fragments were successfully flushed out with the salivary duct catheter. Postprocedure endoscopy confirmed ductal integrity in all 7 ducts. While more studies are needed, this preliminary animal model demonstrates efficacy of endoscopic pneumatic lithotripsy for the management of sialolithiasis.

Outcomes of Holmium Laser–Assisted Lithotripsy with Sialendoscopy in Treatment of Sialolithiasis

Objectives

The purpose of the current study was to compare outcomes and complication rates of sialolithiasis treated with intracorporeal holmium laser lithotripsy in conjunction with salivary endoscopy with those treated with simple basket retrieval or a combined endoscopic/open procedure.

Study Design

Case‐comparison study.

Setting

Tertiary hospital.

Methods

Review of prospectively collected data of patients who underwent treatment for sialolithiasis by the senior author during 2011 to 2013. Patient demographics, operative techniques, surgical findings, clinical outcomes, and complications were recorded. Additional information regarding symptoms and satisfaction with treatment was obtained via standardized telephone questionnaire at the time of the data analysis.

Results

Thirty‐one patients were treated for sialolithiasis. Sialoliths averaged 5.9 mm in size (range, 2‐20 mm) and were comparable between both groups. Sixty‐eight percent were in the submandibular gland (n = 21), with the remaining 32% in the parotid gland (n = 10). Fifty‐two percent of patients (n = 16) were treated endoscopically with intracorporeal holmium laser lithotripsy, while the remaining 48% (n = 15) were treated with salivary endoscopy techniques other than laser lithotripsy. Successful stone removal without additional maneuvers occurred in 81% of the laser cases and 93% of the nonlaser group. Patients in the laser group reported an average improvement of symptoms of 95% compared with 90% of the nonlaser group when adjusted for outliers. Complications in all patients included ductal stenosis (n = 2) and salivary fistula (n = 1).

Conclusion

The results of our series show favorable results with the use of intracorporeal holmium laser lithotripsy for the endoscopic management of sialolithiasis with minimal adverse events.

Interventional sialendoscopy with endoscopic sialolith removal without fragmentation

We performed a retrospective analysis to review the results and complications of sialendoscopy and to identify the overall success rate of mechanical stone retrieval without fragmentation in our patients with sialolithiasis. Between 2009 and 2011, 33 patients with sialolithiasis underwent interventional sialendoscopy. Patients with sialoliths larger than 7 mm in the Wharton's duct and 5 mm in the Stensen's duct or intraparenchymal stones were not included in this study. Grasping forceps, wire baskets and graspers was used for stone removal. The mean age at presentation was 41.7 (range, 29-62) years with a male to female ratio of approximately 1:2. The average size of the stones ranged from 2 to 6 mm. The overall success rate for endoscopic stone retrieval was 78 % (26 of 33) and three patients required a combined approach with intraoral incisions for stone removal. The major complication rate was 3 % (1 of 33) caused by submandibular duct perforation. The endoscopic retrieval of salivary stones is a safe and effective technique in selected cases. As instruments for stone fragmentation are expensive and not available everywhere, selecting patients with small and medium sized stones could lead to successful results in majority of cases.

Ho:Yag Laser for Sialolithiasis of Wharton’s Duct

Objective

To assess the feasibility of intracorporeal lithotripsy with holmium YAG laser under sialoendoscopic guidance for sialolithiasis of Wharton’s duct.

Study Design

Case series with planned data collection.

Setting

Tertiary referral university hospital.

Methods

This study was conducted on 16 patients with sialolithiasis of Wharton’s duct. Diagnosis was confirmed at ultrasound examination. Patients with stones ranging from 5 to 8 mm in diameter were enrolled in the study. The selected patients underwent intracorporeal lithotripsy with holmium Yag laser under endoscopic control. Debris was removed using sialoendoscopic forceps or a wire basket during the same procedure. After a 3-month follow-up, radiological tests were rerun.

Results

Stone fragmentation was possible in all cases. All patients experienced a regular postoperative course. Postoperative ultrasound examinations revealed residual stones in 3 patients, 1 of whom was asymptomatic. Three patients complained of residual symptoms after 3 months of follow-up. These patients were treated successfully during a second sialoendoscopic procedure.

Conclusions

In our experience, endoscopic laser lithotripsy was proved to be a feasible technique for Wharton’s duct lithiasis in clinical practice.

Sialendoscopy: a new diagnostic and therapeutic tool

BACKGROUND

Sialendoscopy is a recently developed minimally invasive diagnostic and therapeutic procedure for the management of obstructive diseases of the salivary glands. This report describes our early experience with this new tool and compares our results with the literature data.

MATERIAL AND METHODS

This was a retrospective analysis of the 33 first cases treated at a teaching hospital from October 2009 to June 2011.

RESULTS

The success rate for diagnostic sialendoscopy was 94%. Sialolithiasis was found in 19 cases and salivary duct stenosis in 11; no canal anomaly was found in two cases. The success rate for stone removal was 79%, while treatment of strictures failed in four cases. Longer surgical experience led to shorter operating times and improved indications as well as better therapeutic outcomes. There were no complications.

CONCLUSION

Sialendoscopy is a safe technique that can easily be learned by surgeons familiar with endoscopic surgery. However, practical experience is needed to reduce operating times, lower failure rates and determine its precise indications.