Efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones: a systematic review and meta-analysis

Background Peroral cholangioscopy with intraductal lithotripsy facilitates optically guided stone fragmentation of difficult biliary stones refractory to conventional endoscopic therapy. The aim of this study was to evaluate the efficacy and safety of peroral cholangioscopy with intraductal lithotripsy for difficult biliary stones. Methods Searches of PubMed, EMBASE, Web of Science, and Cochrane databases were performed in accordance with PRISMA and MOOSE guidelines. Measured outcomes included overall fragmentation success, single-session fragmentation and duct clearance, and rate of adverse events. Sensitivity and subgroup analyses were performed based upon cholangioscopy technique and type of lithotripsy (laser versus electrohydraulic). Heterogeneity was assessed with I-2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. Results 35 studies were included with 1762 participants (43.4% men; mean age 61.5 [standard deviation (SD) 11.0]). Prior cholecystectomy had been performed in 37% of patients, with a mean number of 1.6 (SD 0.5) ERCPs performed prior to lithotripsy. Mean stone size was 1.8 (SD 0.3) cm. Peroral cholangioscopy with intraductal lithotripsy achieved an overall stone fragmentation success of 91.2% (95%CI 88.1%-93.6%; I-2 =63.2%) with an average of 1.3 [SD 0.6] lithotripsy sessions performed. Complete single-session fragmentation success was 76.9% (95%CI 71.6%-81.4%; I-2 =74.3%). The adverse events rate was 8.9% (95%CI 6.5%-12.2%; I-2 =60.6%). Mean procedure time for peroral cholangioscopy was 67.1 (SD 21.4) minutes. There was no difference in overall fragmentation rate or adverse events; however, laser lithotripsy was associated with a higher single-session fragmentation rate and shorter procedure time compared with electrohydraulic lithotripsy. Conclusions Peroral cholangioscopy with intraductal lithotripsy appears to be a relatively safe and effective modality for difficult biliary stones.

Automated summary

The study demonstrated that peroral cholangioscopy with intraductal lithotripsy is a relatively safe and effective modality for difficult biliary stones. The overall stone fragmentation success rate was high, with laser lithotripsy showing advantages in single-session fragmentation rate and procedure time compared to electrohydraulic lithotripsy.