Aims
Endoscopic retrograde cholangiopancreatography (ERCP) is the first-line therapy for choledocholithiasis; standard techniques—extraction baskets/balloons and mechanical lithotripsy—clear most stones. Difficult stones can be successfully approached with cholangioscopy-guided intraductal lithotripsy using electrohydraulic (EHL) or laser (LL) energy. The choice between EHL and LL remains debated. Our aim is to compare efficacy and safety between EHL and LL in the management of large difficult biliary stones.
Methods
We have included all intraductal lithotripsy procedures carried out from November 2021 to October 2025.
Results
32 adult patients (M/F: 12/20) with a mean age of 80 years were included. 18 patients underwent EHL lithotripsy and 14 LL. All procedures were performed in general anesthesia. Patients and stones characteristics were reported in the tab 1. Complete ductal clearance was achieved in 16/18 (89%) EHL patients and 13/14 (93%) LL patients. First-session clearance occurred in 13/16 (81%) with EHL and 12/13 (92%) with LL (p=0.39). The mean procedure time was 101.1 vs 105.8 minutes (p=0.35). Biliary stent use was similar (39% EHL vs 28% LL; p=0.45) and not associated with clearance success (p=0.13). Adverse events were rare: mild cholangitis in 1/22 (4.5%) EHL procedures and 1/18 (5.5%) LL procedures (p=0.85). Performance data were reported in tab 2.
Tab. 1
|
|
EHL |
LL |
p |
|
Patients |
18 |
14 |
|
|
Mean age media |
82.61 ± 7.40 |
76.78 ± 7.95 |
0.04 |
|
M/F (n. / %) |
4 (22%) / 14 (78%) |
8 (57%) / 6 (43%) |
0.04 |
|
ASA I-II / ASA III-IV |
4 (22%) / 14 (78%) |
6 (43%) / 8 (57%) |
0.21 |
|
Previous ERCP |
11/18 (61%) |
11/14 (78%) |
0.29 |
|
Multiple stones |
14/18 (78%) |
13/14 (93%) |
0.24 |
|
Mean n. of stones |
2.0 ± 0.76 |
2.5 ± 1.16 |
0.76 |
|
Stone size (cm) |
2.77 ± 0.57 |
2.71 ± 0.51 |
0.45 |
|
Strictures |
1/18 (5%) |
1/14 (7%) |
0.85 |
|
|
EHL |
LL |
p |
|
N. patients |
18 |
14 |
- |
|
N. procedures |
22 |
18 |
0.38 |
|
Procedures per patient |
1.22 ± 0.55 |
1.28 ± 0.72 |
0.38 |
|
Procedure time (min.) |
101.13 ± 28.19 |
105.83 ± 47.13 |
0.35 |
|
Stent placement |
7/18 (39%) |
4/14 (28%) |
0.45 |
|
Complete clearance |
16/18 (89%) |
13/14 (93%) |
0.70 |
|
Clearance at I session |
13/16 (81%) |
12/13 (92%) |
0.39 |
|
Advers events (cholangitis) |
1/22 (4.5%) |
1/18 (5.5%) |
0.85 |
Tab. 2
Conclusions
Cholangioscopy-guided intraductal lithotripsy has markedly improved the management of difficult biliary stones. In our single-center study, both EHL and LL achieved high success rates with a favorable safety profile and low adverse-event rates; no statistically significant differences in efficacy or safety were detected between techniques. Future work should include larger prospective and randomized studies comparing the two techniques.