Combined lithotripsy of mechanical clamping and electrohydraulics in facilitating endoscopic management of refractory residual biliary calculi after surgery

Abstract

Although postoperative cholangioscopy (POC) guided electrohydraulic lithotripsy (EHL) is considered to be a conventional technique for residual biliary calculi, its efficacy still needs to be improved to fit in the managemet of refractory calculi. This study evaluated the efficacy and safety of combined lithotripsy of mechanical clamping and electrohydraulics in fragmentation and removal of refractory calculi. Totally, 281 patients, who suffered from residual biliary calculi after hepatectomy and underwnet POC from August 2016 to June 2018 were involved. The first 128 patients were subjected to conventional EHL, and later consective 153 to combined lithotripsyof mechanical clamping and EHL. Perioperative data, technical information, treatment outcomes and follow-up results were collected. Clinical characteristics were statistically comparable (P > 0.05). The overall POC interventional sessions (2.0 ± 0.65 vs. 2.9 ± 1.21 sessions), average operating time (99.1 ± 34.88 vs. 128.6 ± 72.87 minutes), incidence of intraoperative hemobilia (4.58% vs. 10.93%), cholangitis (6.54% vs. 14.06%), postoperative complications (10.45% vs. 21.87%), T-tube retaining time after first POC (20.7 ± 5.35 vs. 28.1 ± 8.28 days), and treatment costs ($2375 ± 661.72 vs. $3456.7 ± 638.07) were significantly lower in the combined lithotripsy group than those in the EHL group (P < 0.05). There were no differences between the two groups in calculi recurrence at half-a year, or one year follow-up. In conclusion, combined lithotripsy of mechanical clamping and electrohydraulics can safely and effectively benefit postoperative patients along with refractory residual biliary calculi. Although biliary calculus is a benign disease characterized for the presence of intrahepatic bile duct calculi, it may cause serious complications 1,2. Hepatectomy combined with intraoperative cholangioscopy is regarded as the most helpful approach not only for the removal of the intrahepatic calculi and lesions, but also for reducing the risk of calculi recurrence and cholangitis 3. Unfortunately, this technique is not suitable for complicated calculi distributing bilobarly or diffusely 4. In management of complicated calculi, placement of a T-tube drainage for further postoperative cholangioscopy (POC) was feasible, which allows for repeated sessions for calculi extraction 5,6. When dealing with complicated residual biliary calculi such as with large size, hard consistency, or anatomical abnormalities, conventional POC managements including perfusion and basket extraction are often difficult, or even impossible in patients with impacted calculi 7. Among advanced therapeutic strategies including electrohydraulic lithotripsy (EHL), laser lithotripsy, pneumatic lithotripsy and hyperacoustic lithotripsy, the EHL being the most commonly used in clinic because of its efficiency and low costs 8-11. It allows calculi to be crushed by energy absorption, which leads to a build-up of pressure gradients and the formation of shear and tear forces 9 .