Olaya I Brewer Gutierrez1, Noor L H Bekkali2, Isaac Raijman3, Richard Sturgess4, Divyesh V Sejpal5, Hanaa D Aridi1, Stuart Sherman6, Raj J Shah7, Richard S Kwon8, James L Buxbaum9, Claudio Zulli10, Wahid Wassef11, Douglas G Adler12, Vladimir Kushnir13, Andrew Y Wang14, Kumar Krishnan15, Vivek Kaul16, Demetrios Tzimas17, Christopher J DiMaio18, Sammy Ho19, Bret Petersen20, Jong Ho Moon21, B Joseph Elmunzer22, George J M Webster2, Yen-I Chen1, Laura K Dwyer4, Summant Inamdar5, Vanessa B Patrick6, Augustin Attwell7, Amy Hosmer8, Christopher Ko9, Attilio Maurano10, Avik Sarkar11, Linda J Taylor12, Martin H Gregory13, Daniel S Strand14, Ali Raza15, Shivangi Kothari16, Jessica P Harris17, Nikhil A Kumta18, Amar Manvar19, Mark D Topazian20, Yun Nah Lee21, Clayton M Spiceland22, Arvind J Trindade5, Majidah A Bukhari1, Omid Sanaei1, Saowanee Ngamruengphong1, Mouen A Khashab23. 1. Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland. 2. GI-Services, Pancreatobiliary Medicine Unit, University College London Hospitals, London, United Kingdom. 3. Greater Houston Gastroenterology, Houston, Texas. 4. Division of Gastroenterology and Hepatology, Aintree University Hospital, Liverpool, United Kingdom. 5. Division of Gastroenterology and Hepatology, Hofstra-Northwell School of Medicine, Manhasset, New York. 6. Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana. 7. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado. 8. Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan. 9. Division of Gastroenterology and Hepatology, University of Southern California Keck School of Medicine, Los Angeles, California. 10. Division of Gastroenterology and Hepatology, Hospital of Salerno, G. Fucito Center, Mercato San Severino, Italy. 11. Division of Gastroenterology and Hepatology, UMassMemorial Health Center, Worcester, Massachusetts. 12. Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah. 13. Division of Gastroenterology and Hepatology, Washington University in St. Louis School of Medicine, St. Louis, Missouri. 14. Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia. 15. Division of Gastroenterology and Hepatology, Houston Methodist Hospital, Houston, Texas. 16. Division of Gastroenterology and Hepatology, University of Rochester Medical Center - Strong Memorial Hospital, Rochester, New York. 17. Division of Gastroenterology and Hepatology, Stony Brook University School of Medicine, Stony Brook, New York. 18. Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, New York. 19. Division of Gastroenterology and Hepatology, Montefiore Medical Center, New York City, New York. 20. Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. 21. Division of Gastroenterology and Hepatology SoonChunHyang University School of Medicine, Seoul, Korea (the Republic of). 22. Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina. 23. Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland. Electronic address: mkhasha1@jhmi.edu.
Abstract
BACKGROUND & AIMS: It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.
BACKGROUND & AIMS: It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones. METHODS: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct. RESULTS: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001). CONCLUSIONS: In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.