Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis

Abstract

<jats:p>ABSTRACT Introduction: Endoscopic removal of common bile duct stones has a high success rate ranging from 85% to 95%. Bile duct stones &gt;15 mm are difficult and frequently require lithotripsy. Peroral cholangioscopy (POC) allows lithotripsy with similar success rates. Aim: To determine the efficacy and safety of cholangioscopy-guided lithotripsy used in the treatment of difficult to remove bile duct stones vs. conventional therapy. Methods: Search was based in Medline, Embase, Cochrane Central, Lilacs/Bireme. Studies enrolling patients referred for the removal of difficult bile duct stones via POC were considered eligible. Two analyses were carried out separately, one included randomized controlled trials (RCTs) and another observational studies. Results: Forty-six studies were selected (3 RTC and 43 observational). In the analysis there was no statistical significant difference between successful endoscopic clearance (RD=-0.02 CI: -0.17, 0.12/I²=0%), mean fluoroscopy time (MD=-0.14 CI -1.60, 1.32/I²=21%) and adverse events rates (RD=-0.06 CI: -0.14, 0.02/I²=0%), by contrast, the mean procedure time favored conventional therapy with statistical significance (MD=27.89 CI: 16.68, 39.10/I²=0%). In observational studies, the successful endoscopic clearance rate was 88.29% (CI95: 86.9%-90.7%), the first session successful endoscopic clearance rate was 72.7 % (CI95: 69.9%-75.3%), the mean procedure time was 47.50±6 min for session and the number of sessions to clear bile duct was 1.5±0.18. The adverse event rate was 8.7% (CI95: 7%-10.9%). Conclusions: For complex common bile duct stones, cholangioscopy-guided lithotripsy has a success rate that is similar to traditional ERCP techniques in terms of therapeutic success, adverse event rate and means fluoroscopy time. Conventional ERCP methods have a shorter mean procedure time.</jats:p>

Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review

“…In their study, LL had a significantly higher complete ductal clearance rate (95.1%) compared with EHL (88.4%) and ESWL (84.5%), while EHL had a higher post-procedural AEs rate (13.8%, including cholangitis, hemobilia and pancreatitis) compared with ESWL (8.4%) or LL (9.6%). In opposition to these results, a more recent meta-analysis[ 34 ] reported a superiority of EHL vs LL (mean successful endoscopic clearance rate 91.4% and 88.6%, respectively), explaining a more selective study inclusion than that made by Veld et al [ 33 ]. The last published meta-analysis comparing cholangioscopy-guided lithotripsy vs conventional therapy for complex bile duct stones[ 34 ] showed no significant difference between ERCP and cholangioscopy in terms of therapeutic success, AEs rate and mean fluoroscopy time, but a shorter mean procedure time for conventional ERCP methods were found.…”

“…In opposition to these results, a more recent meta-analysis[ 34 ] reported a superiority of EHL vs LL (mean successful endoscopic clearance rate 91.4% and 88.6%, respectively), explaining a more selective study inclusion than that made by Veld et al [ 33 ]. The last published meta-analysis comparing cholangioscopy-guided lithotripsy vs conventional therapy for complex bile duct stones[ 34 ] showed no significant difference between ERCP and cholangioscopy in terms of therapeutic success, AEs rate and mean fluoroscopy time, but a shorter mean procedure time for conventional ERCP methods were found. In detail, cholangioscopy-guided lithotripsy showed a successful endoscopic clearance rate of 88.29% [95% confidence interval (CI): 86.9%-90.7%], first session successful endoscopic clearance rate of 72.7% (95%CI: 69.9%-75.3%), mean procedure time of 47.50 ± 6 min for session, number of sessions to clear bile duct of 1.5 ± 0.18 and adverse event rate of 8.7% (95%CI: 7%-10.9%).…”

“…The majority of patients in the considered studies had a history of failure to remove stones on prior ERCP attempt. Therefore, Galetti et al [ 34 ] concluded that cholangioscopy-guided lithotripsy should be reserved to cases where the conventional techniques failed to achieve initially stone clearance. The majority of data published by Galetti et al [ 34 ] are in line with an older meta-analysis by Korrapati et al [ 35 ].…”

Role of pancreatography in the endoscopic management of encapsulated pancreatic collections – review and new proposed classification

“…Thus, these authors believe it is reasonable to perform a secretin-enhanced MRCP as the first line strategy to evaluate the pancreatic duct, if available[ 20 ]. Otherwise endoscopic pancreatography via an ERCP approach should be performed as the procedure of choice with patients fully aware of the potential for adverse events, though these remain acceptably low[ 17 , 31 - 34 ].…”

Tips and tricks in the endoscopic management of a complex biliary stone in Billroth II gastrectomy

“…No adverse events occurred. In summary, alternative endoscopic techniques to treat difficult stones are feasible, safe, and effective when appropriately selected [5].…”