Cholangioscopy-Guided Lithotripsy in Complex Biliary Lithiasis: Fully Covered Metal Stents to Facilitate Extraction

Aims Intraductal lithotripsy guided by cholangioscopy is currently recommended for complex lithiasis (5% of cases, mainly due to the presence of large stone>15 mm and/or multiple (> 3) impacted stones and intrahepatic stones) in which conventional techniques are likely to fail. Due to the workload, there is often insufficient time to perform lithotripsy during the initial ERCP. It is generally recommended to place a plastic stent after a failed ERCP to facilitate biliary drainage until the next ERCP session. The objective is to evaluate the efficacy of a fully covered metal stent (FCMS) in improving the success rate of lithotripsy guided by ERCP-cholangioscopy.

Methods Patients suffering from complex lithiasis who underwent an initial ERCP with the insertion of an FCMS to extract stones that could not be extracted using standard methods, followed by elective ERCP-cholangioscopy (Spyglass DS II System, Boston Scientific, US) with electrohydraulic lithotripsy (Autolith Touch Billiary EHL System) [1] [2] [3] [4] [5].

Results A single-center retrospective study (2019-2023) was conducted with 22 patients (28 cholangioscopies, 28 lithotripsy sessions) suffering from complex choledocholithiasis who underwent an initial ERCP in which stone extraction failed. Adequate biliary drainage was achieved with FCMS in 100% of cases. Elective ERCP with electrohydraulic lithotripsy via cholangioscopy was performed 1.5–2 months later. After stent removal, all cases showed a papillary orifice greater than 1 cm and a reduction in stone size greater than 5 mm (an initial median size of 25+5 mm), as observed in cholangiography. The success rate of lithotripsy in a single session was 86% (19 patients). The complex choledocholithiasis was completely resolved in 95.5% cases (21 patients): one case with a larger stone size (40 mm) required three sessions of litotripsy; another case with multiple stones and stone diameter>25 mm required two sessions. In 4.5% (1 patient) cases with the intrahepatic duct stone, failed to achieve extraction despite three sessions of litotripsy, leading to elective surgery. Serious adverse events occurred in 2/28 cholangioscopies (7%), and included one pancreatitis and one cholangitis, all resolved within 1 week.

Conclusions The insertion of FCMS during the initial ERCP after complex stone extraction failure may increase the success rate of subsequent ERCP-lithotripsy guided by cholangioscopy. This is likely due to sustained dilation of the distal bile duct papilla and enhanced stone size reduction from improved bile flow compared to plastic stents. The small sample size is a limitation of this study. Multicenter comparative studies with larger patient cohorts are needed to assess the cost-effectiveness of this strategy within the treatment algorithm of complex biliary lithiasis.

Publication History

Article published online:
27 March 2025

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